22nd Floor, A Wing, Marathon Futurex, Quotation No.: Proposal/Application No.

:
N.M. Joshi Marg, Lower Parel (East) Mumbai - 400013.
CIN: U66010MH2007PLC167164
IRDAI Registration no. 135 501434778
Toll Free: 1800 2090 502.
E-mail: [email protected], www.ageasfederal.com

COMMON PROPOSAL FORM

Channel BANCASSURANCE
Ageas Federal Employee Code 117928
Distributor name FEDERAL BANK
Business vertical BBG Servicing branch name BRANCH OFFICE FEDERAL BANK - KUNDAPUR
Bank Customer ID 138202323 Servicing branch code 2014
SP (Branch employee code) 20710 ACK/POS number BBG
Distributor code 1000049636 Cheque deposit date/
09-Jun-2023
Manager code NA Fund transfer date
Insurance executive NA Application receipt date 09-Jun-2023
Client ID number Urban NA Rural NA
Type of Cover: Individual
*Staff Policy: No
*Staff policies are the policies issued on the lives of staff and agents of Ageas Federal Life Insurance Co. Ltd., the staff of the joint venture partners and on the lives of their spouses,
parents or children.
IN UNIT LINKED PLANS, THE INVESTMENT RISK IN THE INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER. Linked Insurance products do not offer any liquidity during
the first five years of the contract.The policyholders will not be able to surrender/ withdraw the monies invested in Linked Insurance Products completely or partially till the end of fifth year.
General instructions & warnings: 1. While answering questions in the proposal form and providing any other information in respect of the insurance, the proposer and person to be insured must
make a full and frank disclosure of all material facts.If a full and frank disclosure is not made of all material facts, or if any material fact is misrepresented, the policy issued is liable to be
cancelled with immediate effect in accordance with section 45 of insurance act, 1938 as amended from time to time.Further details on this section are provided on page 9.2. Please read carefully
the sales literature to understand the product clearly. 3. All corrections made in the proposal form must be countersigned by the proposer. 4. Commencement of risk will be only after completion
of underwriting and issuance of policy. 5. Nomination facility is available under Part II. Please use this facility. 6. Please fill the proposal form in block capitals and tick option chosen wherever
applicable. 7. The requirement of disclosure of material information in the proposal form or policy apply both to the insured and the insurer.

PART-I: DETAILS OF PERSON TO BE INSURED (To be filled in block letters)

1. Title MR
2. Name FIRSTNAME: RAHUL MIDDLENAME: LASTNAME: N
3. Date of birth 31-Aug-1999 4. Gender Male
5. Father/ Spouse's Name FIRSTNAME: NAVEEN MIDDLENAME: MYSORE LASTNAME: RAMACHANDRARAO
6. Mother's Name FIRSTNAME: RAJANI MIDDLENAME: LASTNAME: .
7. Marital status MARRIED
8. Nationality INDIAN
If nationality is other than Indian then please submit duly filled Nationality Questionnaire.
a) Are you a tax resident of any country other than India ? No
9. Additional details for Foreign Account Tax b) Are you a citizen of USA (Including green card holder) ? No
Compliance Act (FATCA)/Common Reporting If answer to any of the above question is yes, please submit the FATCA declaration.
Standard (CRS) I agree to submit the FATCA/CRS declaration within 30 days in case the above provided information changes or
ceases to be true.

10. Educational qualification GRADUATE

11. Mailing address Address Line 1: 79, 6TH CROSS , 9TH MAIN,
(Please provided your present residential Address Line 2: SARASPATHI PURAM,
address.Office address is not acceptable.)
Landmark: MYSORE ,
City: MYSURU
State: KARNATAKA PIN: 570009
12. Telephone/Mobile/Email Mobile(With Country Code): +917795203031 Tel(With STD Code):
Email: [email protected]
13. Permanent address Address Line 1: 79, 6TH CROSS , 9TH MAIN,
(If different from mailing address) Address Line 2: SARASPATHI PURAM,
Landmark: MYSORE ,
City: MYSURU
State: KARNATAKA PIN: 570009
14. Occupation BUSINESS OWNER
Name of organisation: EXPORT IMPORT BUSINESS
Designation: BUSINESS
15. Nature of work MOSTLY ADMINISTRATIVE
16. Length of Service / Business
17. Annual income INR 800000.00
18. Permanent Account Number (PAN) CHHPN9656D
19.Electronic Insurance Account Number (eIA)*
*If no eIA then mention the repository option NSDL

AFLI/CPF/V18/042023 OUT : 1001 Page 1

 22nd Floor, A Wing, Marathon Futurex,
N.M. Joshi Marg, Lower Parel (East) Mumbai - 400013.
Quotation No.: Proposal/Application No.:
CIN: U66010MH2007PLC167164
IRDAI Registration no. 135 501434778
Toll Free: 1800 2090 502.
E-mail: [email protected], www.ageasfederal.com

PART-II: DETAILS OF PROPOSER, NOMINEE AND APPOINTEE

A. Proposer details (If different from person to be insured)
1. Title MR
2. Name FIRSTNAME: RAHUL MIDDLENAME: LASTNAME: N
3. Date of birth 31-Aug-1999 4. Marital status MARRIED
5. Father/ Spouse's Name FIRSTNAME: NAVEEN MIDDLENAME: MYSORE LASTNAME: RAMACHANDRARAO
6. Mother's Name FIRSTNAME: RAJANI MIDDLENAME: LASTNAME: .
7. Address for correspondence (If Address Line 1: 79, 6TH CROSS , 9TH MAIN,
different from that of person to be Address Line 2: SARASPATHI PURAM,
insured.)
Landmark: MYSORE ,
State: KARNATAKA
City: MYSURU PIN: 570009
8. Telephone/Mobile/Email Mobile(With Country
Tel(With STD Code):
Code): +917795203031
Email: [email protected]
9. Nationality INDIAN
If nationality is other than Indian then please submit duly filled Nationality Questionnaire.
a) Are you a tax resident of any country other than India ? No
10. Additional details for Foreign b) Are you a citizen of USA (Including green card holder) ? No
Account Tax Compliance Act If answer to any of the above question is yes, please submit the FATCA declaration.
(FATCA)/Common Reporting Standard I agree to submit the FATCA/CRS declaration within 30 days in case the above provided information
(CRS) changes or ceases to be true.

12. Relationship with person to be

11. Gender Male Self
insured
13. Educational qualification GRADUATE
14. Occupation BUSINESS OWNER
Name of organisation/Business EXPORT IMPORT BUSINESS
Designation: BUSINESS
15. Nature of work MOSTLY ADMINISTRATIVE
16. Length of Service / Business
17. Annual income INR 800000.00
18. Permanent Account Number (PAN) CHHPN9656D
19. Electronic Insurance Account
NA
Number (eIA)*
*If no eIA then mention the repository
NSDL
option
B. Nominee Details: Applicable only if person to be insured and proposer are the same (As per Section 39 of the Insurance Act, 1938, as
amended from time to time)
Name of nominee Gender Relationship Date of birth Address & contact number %Share
79, 6TH CROSS , 9TH
MAIN,,SARASPATHI
First:NAKUL Middle: PURAM, MYSORE ,
Male BROTHER 18-Jun-2005 100
Last: N KARNATAKA MYSURU
570009 - 7795203031
If the nominee is minor, please mention the name of appointee (appointee has to be an adult):RAJANI RAO DOB of Appointee :05-Sep-1977
Relationship of appointee with nominee (appointee has to be different from the person to be insured): MOTHER Gender: FEMALE

AFLI/CPF/V18/042023 OUT : 1001 Page 2

 22nd Floor, A Wing, Marathon Futurex, Quotation No.: Proposal/Application No.:
N.M. Joshi Marg, Lower Parel (East) Mumbai - 400013.
CIN: U66010MH2007PLC167164
IRDAI Registration no. 135 501434778
Toll Free: 1800 2090 502.
E-mail: [email protected], www.ageasfederal.com

PART-III: PLAN DETAILS

A: Plan, Sum Assured, Benefit details
Plan Name AGEAS FEDERAL LIFE INSURANCE GUARANTEED Plan Option Regular UIN: 135N048V07
WEALTH PLAN
Life Stage Cover NA (For iSecure Plan)
Sum Assured details
Maturity / Guaranteed Sum Assured (in Rs) NA (For Participating plans )
Sum Assured (in Rs) 500605 (For Non Participating Protection plans and ULIP plans)
Monthly Income at inception (in Rs):NA (For Income Protect Plan)
Maturity Sum Assured (in Rs):NA (For Non Participating Saving Plan)
Benefit details
Guaranteed Annual Payout / Guaranteed Regular Income (in Rs) (For Non Participating Saving and Annuity Plans)
Payout Details (For Annuity and Assured Income Plan):NA
Payout Frequency:YEARLY
Critical Illness Sum Assured (in Rs):NA (For Wealth Plus Critical Protection Plan only)
Accidental Death Sum Assured (in Rs):NA (For iSecure Plan)
B. Fund details
1. Systematic Allocator
Systematic Allocator NA
(If 'Yes' is ticked please leave the section below blank)
2. Fund name Fund allocation
Equity Growth Fund %
Income Fund %
Midcap Fund %
Bond Fund %
Pure Fund %
Bond Fund II %
Aggressive Asset Allocator Fund %
Moderate Asset Allocator Fund %
Cautious Asset Allocator Fund %
Fund Name %
Fund Name %
Please refer to the notes on Page 9 for details on fund SFIN codes
100%
Total

AFLI/CPF/V18/042023 OUT : 1001 Page 3

 22nd Floor, A Wing, Marathon Futurex, Quotation No.: Proposal/Application No.:
N.M. Joshi Marg, Lower Parel (East) Mumbai - 400013.
CIN: U66010MH2007PLC167164
IRDAI Registration no. 135 501434778
Toll Free: 1800 2090 502.
E-mail: [email protected], www.ageasfederal.com

Part-IV: PREMIUM AND PAYMENTS DETAILS

A.Premium details
Premium Payment Term Policy Term Total Payment
Instalment Premium/Purchase Price (for Annuity Plans only) payable plus Goods &
Services Tax and cess as applicable (in Rs)
7yrs 14yrs 52250.00
YEARLY (For available premium payment options & modes for your plan please refer the sales literature and your
Premium mode
benefit illustration.)
*Monthly mode is available only for NACH. For monthly mode two months premium to be paid in advance.
B.Payment details (First premium)
Direct Debit
Premium in cash should be less than or equal to Rs 49,000.Please ask for receipt of payment, whenever premium is paid.
Bank name:FEDERAL BANK Bank branch:BRANCH OFFICE FEDERAL BANK - KUNDAPUR
Bank account number:20140100022243 Amount:52250.00
In case of Cheque / DD, additionally please provide
Cheque / DD number:fb20710 Cheque/ DD date:09-Jun-2023
C. Bill Desk details
Reference No. Amount Type Date

D. Payment details (Renewal premium)

Others - Cheque
Please ask for receipt of payment, whenever premium is paid
*Please issue the cheque and demand draft in the name of 'Ageas Federal Life Insurance Co Ltd'.+If you want to opt for the NACH facility, please submit a filled up NACH mandate form along
with the copy of a cancelled cheque. Irrespective of the payment method that you choose, please provide a statement or the copy of a cancelled cheque of your bank account. All the payments
under your policy, as and when due, will be made into the same bank account.
E. Bank details of proposer
Bank account number 20140100022243
Bank & branch name FEDERAL BANK
Bank account type Savings
Mandatory for NRIs (Account
type)
MICR code 576049202(It is the 9 digit code after the cheque number on your cheque)
F. Details of existing and simultaneous applications for life insurance if any, on Proposer and/or Insured Person
(Ageas Federal and other companies):
1 Are you an existing customer of Ageas Federal Life Insurance Company Limited? No
2 Have you concurrently / simultaneously applied for any life/ Health/ Critical Illness/ Disability/ Accident insurance cover if any with us or
No
any other companies, on Proposer and/or Insured Person which is still under consideration?
3 Have you concurrently / simultaneously applied for revival of your lapsed policies with us or any other companies for life/ Health/ Critical
No
Illness/ Disability/ Accident insurance cover if any, on Proposer and/or Insured Person which is still under consideration?
4 Please provide details of existing insurance cover on Proposer and/or Insured Person in the below table. If you do not have any existing
insurance on your life, please mention 'NIL' in Sum Assured column below. Please include any Keyman Insurance, Partnership Insurance,
No
Employer Employee, HUF, MWPA Insurance cover as well If answer to question 1 to 4 is YES, then please provide the complete details
in the below mentioned table.
Has any insurance (Life/ Health/ Critical Illness/ Disability/ Accident) cover or revival request on Proposer and/or Insured Person ever
5 been declined, withdrawn, reject, postponed or accepted with modified terms? No
(If Yes,please provide the necessary details in the below mentioned table)

Details of Existing / Simultaneously Applied Insurance Cover on Family Members (Spouse, Parents & Siblings Insurance details in case of
6 No
female or minor life)

AFLI/CPF/V18/042023 OUT : 1001 Page 4

 22nd Floor, A Wing, Marathon Futurex, Quotation No.: Proposal/Application No.:
N.M. Joshi Marg, Lower Parel (East) Mumbai - 400013.
CIN: U66010MH2007PLC167164
IRDAI Registration no. 135 501434778
Toll Free: 1800 2090 502.
E-mail: [email protected], www.ageasfederal.com

PART-V: PERSONAL MEDICAL STATEMENT OF PERSON TO BE INSURED

Please in boxes to indicate choice
1. Height 5.7 Feet/Inches Weight 70 Kgs
Apart from minor ailments such as colds and flu have you received any treatment or have sign and symptom for which consulted with any
2. No
doctor or specialist or undergone surgery or been hospitalized in the last 5 years?
3. Have you gained or lost more than 5 kg weight in last one year other than weight loss program/pregnancy related? NA
Have you suffered from or are suffering from any of the following signs and symptoms or taken consultation or been advised to undergo regular
4.
medical consultation/investigations or treatment including hospitalization, surgery or advised regular treatment or awaiting medicals for:
A) Diabetes / Elevated Blood Sugar? No
B) High Blood Pressure ? No
C) Stroke, Chest Pain, Heart Attack, or any Heart Disease? No
D) Asthma or any other Respiratory Disorder? No
E) Epilepsy, Paralysis, Parkinsons Disease, Multiple Sclerosis or any other Nervous Disorder? No
F) Liver Disease, Gall Bladder Disease or any other Digestive Disorder? No
G) Kidney / Bladder Disease? No
H) Anaemia, Thalassemia or any other Blood Disorder? No
I) Thyroid or any other Endocrine disorder? No
J) Tumor, Abnormal Cyst, any Cancers? No
K) Arthritis or any order Musculoskeletal disorder? No
L) Anxiety, Depression or any other Mental Disorder requiring treatment with antidepressant? No
M) you or your spouse ever been tested positive or received medical advice or treatment or considering to undergo test or awaiting
No
test results for HIV/AIDS, Hepatitis(Other than Hepatitis A and E), Alcoholic Liver Disease or any Sexually Transmitted Diseases?
5. Are there any other health conditions not mentioned above which you would like to inform us? No
If answers to any of the above Questions is Yes, then please give details of Investigations / Treatment / Surgery / Advise and submit attending doctor's
report, Hospital records along with discharge summary if applicable and complete respective questionnaire
(If the space provided above is insufficient, please use additional sheet)

AFLI/CPF/V18/042023 OUT : 1001 Page 5

 22nd Floor, A Wing, Marathon Futurex, Quotation No.: Proposal/Application No.:
N.M. Joshi Marg, Lower Parel (East) Mumbai - 400013.
CIN: U66010MH2007PLC167164
IRDAI Registration no. 135 501434778
Toll Free: 1800 2090 502.
E-mail: [email protected], www.ageasfederal.com

PART-VI: FAMILY HISTORY, HABITS AND LIFESTYLE OF THE PERSON TO BE INSURED

(To be completed only if total sum assured for all existing policies and current proposals from Ageas Federal is greater than Rs.10 lacs or if you have chosen a Term plan / Ageas Federal
Secured Income Insurance Plan / Ageas Federal Wealth Gain Insurance Plan/ Ageas Federal Dream Builder Plan / Ageas Federal Wealth Plus Critical Protection Plan)
1. For female lives only
a) Have you ever suffered/are you suffering from any gynaecological problem? null
b) Are you pregnant at present? If Yes what is the expected date of delivery or last menstural period? null
c) Have you had any complications, Miscarriage, Medical Termination of Pregnancy or Caesarian Section? null
In last 5 years have you remained absent from place of work for more than 7 consecutive days due to illness or injury or have you been
2. No
hospitalized for more than 72 hours ?
3. Do you have or had any form of mental, physical, congenital disability, deformity, defect, abnormality? No
Have you undergone or been advised to or considering to undergo any medical treatment / surgical procedure/investigations/ awaiting
test results for cancer,tumour, abnormal growth or heart disease like Blood tests, Ultrasound (USG), Colour Doppler, Cytology,
4. Echocardiography, ECG, Treadmill / Stress Thallium/Echo, CT Angio, MRI/CT/PET-Scan, Holter test, Tumour markers, Endoscopy, PAP No
smear, Mammography, Colonoscopy, Biopsy/FNAC, Angiography, Angioplasty, Bypass/ any Heart Surgery or X- ray etc. other than pre-
employment/ executive / routine health check up?
Do you consume or have you ever consumed or been advised to quit narcotics, drugs, psychotropic substances, alcohol and tobacco
5. No
consumption in any form?
Substance Consumed If Yes, then the substance and Quantity Consumed Quantity/Day Consuming For
Tobacco NO
Alcohol NO
Drugs not prescribed by doctor NO
Is your occupation associated with the armed forces or with any hazards such as HTV drivers, working at heights, high voltage, climbing
poles, underground, offshore or required to be in contact with explosives, corrosive chemicals,ionization radiations, biological
6. No
contamination, mining, fumes, toxic gases, boilers, furnace, heated or molten metal's or radioactive substances that could render you
susceptible to injuries or illness? If 'Yes', please complete the 'Armed Forces' or Occupation' questionnaire as may be appropriate.
Do you take part or intend to take part in parachuting/gliding/diving/mountaineering/climbing/racing/riding /martial arts/hunting/bungee-
7. jumping/flying other than as a bonafide passenger/or any other hazardous pastimes? No
Please specify: If 'Yes', please complete respective questionnaire).
Are you planning to travel in the next one year or reside abroad other than on holiday? If Yes, please provide details of country & city to
8. No
be visited and purpose of visit along with duration of stay
9. Family History
Have any of your parents or siblings suffered from or diagnosed with any form of tumour, abnormal growth, cyst, cancer, sarcoma, CIS
(Carcinoma in Situ), diabetes or heart conditions like hypertension, coronary artery disease, heart valve disease, stroke, Cardiomyopathy, No
arrhythmia, sudden death, etc prior to age of 60 years?
Family Member Current state of health Current age If deceased, cause of death Age at death
Father Healthy 58 years
If the answer to any of the above questions is 'yes', please give details and provide reports (if available):_______________________________________________________
_________________________________________________________________________________________________________________________
(If the space provided above is insufficient, please use additional sheet.)

AFLI/CPF/V18/042023 OUT : 1001 Page 6

 22nd Floor, A Wing, Marathon Futurex, Quotation No.: Proposal/Application No.:
N.M. Joshi Marg, Lower Parel (East) Mumbai - 400013.
CIN: U66010MH2007PLC167164
IRDAI Registration no. 135 501434778
Toll Free: 1800 2090 502.
E-mail: [email protected], www.ageasfederal.com

PART-VII: MANDATORY DETAILS IN ACCORDANCE WITH AML

(Anti- Money Laundering) GUIDELINES/ and Central KYC (CKYC)
(To be filled by proposer/life assured only. In case the life assured and proposer are different, a separate CKYC annexure need to be filled by life assured.)
Application Type New Update
KYC Number (Mandatory for KYC update request)
Account Type Normal Simplified(For low risk customers) Small
A List of proof required (If KYC number is provided, below details are required only in case of update request)
1. Type of Identification Proof (Any one, to be self attested)
PAN_CARD
UID-No.
2. Residential Proof (Any one, to be self attested)
BANK_ACCOUNT_STATEMENT
Address in the jurisdiction details where applicant is resident outside India for tax purposes
Same as permanent address Same as mailing address
Address
City/Town/Village
State District ZIP/Post Code
ISO 3166 Country
3. Details of related persons
Addition of related person Deletion of related person KYC number of related persons (if available*)
Related person type* NA
Prefix First Name Middle Name Last Name
Name*
4. PROOF OF IDENTITY (Pol) OF RELATED PERSON (If KYC number and name of Related Person is provided, below details are optional) NA
B Income Proof Submitted (Any one, to be self attested by Proposer)
BANK_STATEMENTS
Please Note: Mandatory if annual premium paid is Rs 100,000 and above. Bank cash-flows statements must not be more than 6 months old. Others
include documents as decided by the Company from time to time.
C Other details
1. Has the person to be insured or proposer or payor ever been convicted of any criminal proceedings in India or abroad? No
If yes please provide details :
2. Is the person to be insured, nominee or proposer or payor a Politically Exposed Person*? No
If yes please provide details :
*Politically Exposed Person (PEP) are individuals who are or have been entrusted with prominent public functions including in a foreign country.e.g., Heads of States/Governments, senior
politicians,senior government/judicial/military officers, senior executives of state owned cooperation, important political party officials,etc.
3. Is the proposer / Nominee / Premium payor a Trust, Charity, NGO or organization receiving donations? NA
D ATTESTATION/FOR OFFICE USE ONLY
Documents received Self attested
KYC verification carried out by specified person in
case of Corporate Agent, Agent in case of Agency and by Institution Details
employee sourcing business in case of Direct sale.
Date DD MM YYYY Name

Name code
Code
Designation
Branch

AFLI/CPF/V18/042023 OUT : 1001 Page 7

 Quotation No.: Proposal/Application No.:
501434778

PART-VIII A: DECLARATION & AUTHORISATION

I declare and warrant on my behalf and on behalf of the person whose life is to be insured that the I consent, authorize and direct any doctor, hospital, or employer to disclose to Ageas Federal any
answers given in response to the questions above, and the statements made in this proposal or information relating to my present state of health and past health history. I agree and declare that
otherwise in support of this proposal are true, correct and complete in all respects, and there is no in event of my being medically examined, answers given by me to the medical examiner acting on
other information material to the application that has not been disclosed. Further, I understand, that behalf of Ageas Federal shall be deemed to be part of the statements and answers given in this
the statements and this declaration made under this proposal will be the basis of contract of proposal and subject to this declaration and warranty. I declare that the contents of this proposal
assurance between me and Ageas Federal. form have been fully explained to me and I have fully understood the significance of the same. I
agree that the policy shall not commence till Ageas Federal accepts and underwrites this proposal
And I further agree that if after the date of submission of the proposal but before the issue of policy and communicates to me the commencement of the policy.
there is (i) any change in my occupation or any adverse circumstances connected with my financial
position or the general health of my self or the general health of the person whose life is to be I hereby provide permission to Ageas Federal to use my sensitive personal data or information
insured or that of any member of my/ our family occurs or (ii) if a proposal for assurance or an [as provided under Information Technology (Reasonable security practices and procedures and
application for revival of a policy on my life or on the life of the person to be Insured made to any sensitive personal data or information) Rules, 2011 and to disclose the same to any third party as
insurer is withdrawn or dropped, deferred, declined or accepted at an increased premium or as per applicable laws, in connection with this proposal or resulting policy. This permission shall
subject to a lien or on terms other than as proposed, I shall forthwith intimate the same to the remain in force & valid for any future instance requiring such permission, in connection with this
Ageas Federal in writing. proposal or resulting policy.

PART-VIII B: DECLARATION & AUTHORISATION

1 I have read, understood and agreed to the Benefit Illustration No BIN2271459 and Financial Need Analysis received by me. Yes
I declare that the contents of this proposal form have been fully explained to me and I have fully understood the significance of same. I
2 agree that the policy shall not commence till Ageas Federal accepts and underwrites this proposal and communicates to me the Yes
commencement of the policy.
I understand that in case of fraud or misstatement by me action will be initiated as per provisions of Section 45 of the Insurance Act, 1938,
3 Yes
as amended from time to time.
I hereby declare that the details furnished for KYC are true and correct to the best knowledge and belief and I undertake to inform you of
4 any changes therein immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am Yes
aware that I may be held liable for it.
I hereby consent to receiving information from Central KYC Registry through SMS and Email on the above registered phone number and
5 Yes
email address.
I also authorize Ageas Federal to use my mobile number/email id as mentioned above for sending alerts relating to this proposal and
6 Yes
resulting policy.
7 I authorise Ageas Federal to also send me the Policy Document electronically. Yes
I declare that the premiums paid have not been generated from the proceeds of any criminal activities/offences and I shall abide by and
8 Yes
conform to the Prevention of Money Laundering Act, 2002 or any other applicable laws.

This form is verified with received otp on 09/06/2023,16:52:16

Signature/ Thumb impression of the Person to be Insured (Where person to be insured is minor, only Signature/ Thumb impression of the Proposer (If different from the Person to be Insured)
proposers signature is required)
*Stamp required in place of proposal signature for business insurance cases like HUF, Employer-Employee, Keyman and Partnership etc.

Place: Place: MYSURU

Date: Date: 09/06/2023

AFLI/CPF/V18/042023 OUT : 1001 Page 8

 Quotation No.: Proposal/Application No.:
501434778

Declaration by the Advisor/Corporate Agent/Broker/Distributor

I certify that the customer has understood the proposal form completely and the facts disclosed therein are true and correct to the best of my knowledge and belief. I have also verified the completeness
of documentation.
I further declare that to the best of my knowledge the premium amounts are not sourced from the proceeds of any criminal activities/offences listed in the Prevention of Money Laundering Act, 2002 or
under any other applicable laws. Should there be any adverse change in my opinion of the integrity or reputation of the applicant, I shall inform Ageas Federal Life Insurance Company Limited
immediately.

Signature of Advisor/Specified person from Corporate agent/Broker/Distributor along Name:

with stamp
Place:
Date: 09/06/2023 This form is verified with received otp on 09/06/2023,16:52:16

Specified Person /
Distributor/Advisor Code:
For Direct Marketing signature of the Ageas Federal employee along with stamp Name:

Place:
Date:

Employee code:

PART -VIII C: DECLARATION & AUTHORISATION

(Declaration to be given if proposal is signed in Vernacular/Thumb impression or filled by salesperson)
I , (name) have explained the contents of this proposal to the ( P ro p o s e r) in
language) and ensured that the contents have been fully understood by him/ her. I have accurately recorded the Proposer's responses to the information sought in
the proposal form and I have read out the responses to the Proposer and he/ she has confirmed that they are correct.

Signature of the person making the declaration: Address of the person making the declaration:

Place: Date:

I have understood the contents of this proposal explained to me in language and confirm that the responses Signature / Thumb Impression of the proposer
provided by me are correct
Place: Date:

Notes
Fund names and SFIN Codes
Equity Growth Fund:SFIN Code-ULIF04110/03/08EQOPP135. Midcap Fund:SFIN Code-ULIF06801/01/10MIDCAP135. Pure Fund: SFIN Code- ULIF07201/09/10PURE135. Bond Fund:SFIN Code-
ULIF04010/03/08BOND135. Income Fund: SFIN Code-ULIF04210/03/08INCOME135. Aggressive Asset Allocator Fund:SFIN Code-ULIF04810/03/08AGGRESSIVE135. Moderate Asset Allocator
Fund:SFIN Code-ULIF04910/03/08MODERATE135. Cautious Asset Allocator Fund:SFIN Code-ULIF05010/03/08CAUTIOUS135.Bond Fund II:SFIN Code-ULIF07731/10/17BOND2135. Please refer
to the Brochure / Website for available Funds and SFIN codes for your selected plan.

Sections 41 and 45 of the Insurance Act, 1938 as amended from time to time
SECTION 41 OF THE INSURANCE ACT, 1938 as amended from time to time: The prove that the misstatement of or suppression of a material fact was true to the best of his
Insurance Act, 1938 as amended from time to time, prohibits an agent or any other person from knowledge and belief or that there was no deliberate intention to suppress the fact or that such
passing any portion of his commission to the customer whether as incentive or rebate of premium. mis-statement of or suppression of material fact are within the knowledge of the insurer: Provided
Section 41 of the Act states: (1) No person shall allow or offer to allow, either directly or indirectly, that in case of fraud, the onus of disproving lies upon the beneficiaries , in case the policyholder is
as an inducement to any person to take out or renew or continue an insurance in respect of any not alive. 4) A policy of life insurance may be called in question at any time within three years from
kind of risk relating to lives or property in India, any rebate of the whole or part of the commission the date of issuance of the policy or the date of commencement of risk or the date of revival of
payable or any rebate of the premium shown on the Policy, nor shall any person taking out or policy or the date of the rider to the policy, whichever is later, on the ground that any statement of
renewing or continuing a policy, accept any rebate, except such rebate as may be allowed in or suppression of a fact material to the expectancy of the life of the insured was incorrectly made
accordance with the published prospectuses or tables of the Insurer. in the proposal or other document on the basis of which the policy was issued or revived or rider
SECTION 45 OF THE INSURANCE ACT, 1938 as amended from time to time: 1) No issued: Provided that the insurer shall have to communicate in writing to the insured or the legal
policy of life insurance shall be called in question on any ground whatsoever after the expiry of representatives or nominees or assignees of the insured the grounds and materials on which such
three years from the date of the policy, i.e., from the date of issuance of the policy or the date of decision to repudiate the policy of life insurance is based: Provided further that in case of
commencement of risk or the date of revival of the policy or the date of rider to the policy, repudiation of the policy on the ground of misstatement or suppression of a material fact, and not
whichever is later. 2) A policy of life insurance may be called in question at any time within three on grounds of fraud, the premiums collected on the policy till the date of repudiation shall be paid
years from the date of the issuance of policy or the date of commencement of risk or the date of to the insured or the legal representative or nominee or assignees of the insured within a period of
revival of the policy or the date of rider to the policy, whichever is later, on the ground of fraud. ninety days from the date of such repudiation. Provided further that nothing in this section shall
Provided that the insurer shall have to communicate in writing to the insured or the legal prevent the insurer from calling for proof of age at any time if s/he is entitled to do so, and no policy
representatives or nominees or assignees of the insured the grounds and materials on which such shall be deemed to be called in question merely because the terms of the policy are adjusted on
decision is based. 3) Notwithstanding anything contained in the sub-section (2) , no insurer shall subsequent proof that the age of the Life Insured was incorrectly stated in the proposal.
repudiate a life insurance policy on the ground of fraud of the insured can

AFLI/CPF/V18/042023 OUT : 1001 Page 9

Benefit Illustration - Ageas Federal Life Insurance Guaranteed Wealth Plan (A non-linked, non-participating life insurance plan)
(Product Unique Identification No - 135N048V07)

Personal details Quotation Number 3280843

Name of the Proposer: RAHUL N Proposal / Application No. 501434778
Age: 23 Name of the Product Ageas Federal Life Insurance Guaranteed Wealth
Plan
Gender: Male
Tag Line A non-linked, non-participating life insurance plan
Name of the Life Assured RAHUL N
Unique Identification Number 135N048V07
Age: 23
Year 1-4.5%
Gender: Male GST Rate
Year 2-2.25%
Policy Term 14
GSTIN Number- available for Proposer(Yes/No) NA
Premium Payment Term 7
State of Mailing Address (Proposer) Karnataka
Amount of Instalment Premium 50,000
Location of Sale Karnataka

This Benefit Illustration is intended to show year-wise premiums payable and benefits under the policy.
Po l i cy D e ta i l s
Policy Option Regula r Income Benefit Ma turity Sum As s ured 0
Dea th Sum As s ured 5,00,000

Pre m i u m D e ta i l s
Tota l Ins ta lment Premium
Ins ta lment premium without GST a nd ces s 50,000
Ins ta lment premium with Firs t Yea r GST a nd ces s 52,250
Ins ta lment premium with GST a nd ces s Second Yea r onwa rds 51,125

AFLI/BI/Guarant eed Wealt h Plan/Version 1.1/09 Jun 2023/3280843/Bancassurance

 (Amount in Rupees)

Po l i cy b e n e fits : G u a ra n te e d B e n e fits N o n G u a ra n te e d B e n e fits

Po l i cy ye a r An n u a l i z e d G u a ra n te e d An n u a l Pa yo u ts G u a ra n te e d Ma tu ri ty B e n e fit D e a th B e n e fit ( p a ya b l e o n G u a ra n te e d S u rre n d e r Va l u e S p e ci a l S u rre n d e r Va l u e
Pre m i u m ( p a ya b l e a t th e e n d o f ye a r) D e a th )

1 50,000 - - 5,00,000 - -
2 50,000 - - 5,00,000 30,000 52,921
3 50,000 - - 5,00,000 52,500 87,963
4 50,000 - - 5,00,000 1,00,000 1,28,727
5 50,000 - - 5,00,000 1,27,500 1,75,212
6 50,000 - - 5,00,000 1,56,000 2,31,709
7 50,000 - - 5,00,000 1,85,500 2,95,357
8 - 71,515 - 5,00,000 1,89,000 3,25,393
9 - 71,515 - 5,00,000 1,41,985 2,96,072
10 - 71,515 - 5,00,000 91,470 2,57,454
11 - 71,515 - 5,00,000 44,455 2,20,266
12 - 71,515 - 5,00,000 - 1,73,781
13 - 71,515 - 5,00,000 - 1,21,576
14 - 71,515 - 5,00,000 - 64,364

The above tables should be read in conjunction with important notes.

Note-Annualized Premium excludes underwriting extra premium,frequency loadings on premiums, the premiums paid towards the riders if any,and Goods and Services Tax and cess.

Important Notes:

1) This illustration is for a healthy individual and acceptance of the proposal is subject to underwriting.
2) The illustration assumes the payment of all premiums on due dates.
3) Goods and Services tax and cess as applicable , will be levied as per the extant laws.
4) The values shown are for illustrative purposes only.Please read the sales literature and policy document for details.

Declaration by Proposer:

I,____________ , having received the information, with respect to the above have understood the above statement before entering into the contract.

Name:
Place :
Date : Signature of Proposer :

AFLI/BI/Guarant eed Wealt h Plan/Version 1.1/09 Jun 2023/3280843/Bancassurance

Marketing official's name: I,____________ , have explained the premiums and benefits under the product fully to the policyholder.

Place :
Date :
Company Seal: Signature of Advisor/ Specified person / Marketing Official:

Note: This BI is computer generated and does not require signature. The Policyholder and Specified person has signed the 'Customer Declaration and Authorization Form' confirming to have read and
understood this Benefit illustration (BI).

AFLI/BI/Guarant eed Wealt h Plan/Version 1.1/09 Jun 2023/3280843/Bancassurance