Proposal No.

KYC No.:
Solution No.

Proposal Form
Please fill Code Name Policy Type: Rural Urban
IA/FPC/CSO Channel Type: Agency Broker BABP DM IMF PROPOSED
/DM/ARM/ISP
Type of Cover: Individual Employer-Employee
INSURED
Specified Person MWP HUF General Partnership Paste here (do not
Key Partnership pin or staple)
PNB MetLife Key Person Solution
* A recent passport
Branch
Employee Discount: PNB MLI Employee size photograph
PNB Employee J&K Bank Employee (not more than 6
Relationship Branch
Name of CA/Broker months old)
/Referral Company Account Type: Normal Simplified
/M I A Small (For low risk customers)
IN UNIT- LINKED INSURANCE PRODUCT, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER
Please read all the questions carefully and complete the details required truthfully in relation to your health and habits, within your knowledge as on the date of the submission of this proposal. The
information provided by you will form the basis for issuance of the policy. Please ensure that you affix your signature in all the places as stated. In certain places more than one signature is required. This is
in your own interest. Proposal Form needs to be filled in BLACK Ink only. All documents submitted along with this the Proposal Form should be attested by the Proposed Insured and Proposed Holder.
The Proposal Form and all rights, obligations, and liabilities arising thereunder, shall be construed, determined, and enforced in accordance with the laws of India. State code and Country code to be
updated as per Indian motor vehicle, 1988 and ISO 3166 country code respectively. Corrections or over writing, if any, must bear full signature of the Applicant. The life insurance policy is neither a
Fixed/Recurring deposit/Mutual fund or surrogate of any of the loan products applied with the bank and not a pre-condition for opening a bank account/availing a loan or locker facilities etc. Participation
for availing the insurance policy is purely on voluntary basis.
A. Proposed Insured Details (To be filled in BLOCK LETTERS and all FIELDS are mandatory)
1. Name (Mr./Mrs./Ms./Dr./Master/Other): F I R S T M I D D L E L A S T
(Same as ID Proof)
2. Maiden Name (Ms./Dr./Other): F I R S T M I D D L E L A S T

3. Father’s Name (Mr./Dr./Other): F I R S T M I D D L E L A S T

4. Mother’s Name (Ms./Mrs./Dr./Other): F I R S T M I D D L E L A S T

5. Spouse Name (Mr./Mrs./Dr./Other): F I R S T M I D D L E L A S T

6. Date of Birth: D D M M Y Y Y Y 7. Place of Birth: (Include Country Name)

8. Gender: M-Male F- Female T- Transgender

9. Citizenship: IN- Indian Others-ISO 3166 Country Code 10. Are you Tax resident of any other country other than India Yes No
[If Yes, please fill up FATCA/ CRS questionnaire and fill point 13 (iii)]
11. Residential Status: Resident Individual Non Resident Indian Person of Indian Origin Foreign National _________________________________________________________
COUNTRY NAME
12. Marital Status: Married Unmarried Others (Specify) ______________________________
13. (i) Current/Permanent/Overseas Address: (Certified copy of anyone of the following Proof of Address [PoA] needs to be submitted)
Address Type: Residential/Business Residential Business Registered Office Unspecified
Address Proof: Passport Driving License UID (Aadhaar) Voter Identity Card NREGA Job Card Simplified Measures Account – Document Type Code
Others ___________________ Please provide the number for the proof submitted ____________________________________

L A N D M A R K C I T Y / T O W N / V I L L A G E

D I S T R I C T P I N / P O S T C O D E S T A T E / U T C O D E
(ii) Correspondence/Local Address
Same as Current/Permanent/Overseas Address (In case of multiple Correspondence/Local Address, please fill annexure A1)

L A N D M A R K C I T Y / T O W N / V I L L A G E

D I S T R I C T P I N / P O S T C O D E S T A T E / U T C O D E

(iii) Address in the Jurisdictions details where applicant is Resident Outside India for tax purposes
Same as Current/Permanent/Overseas Address Same as Correspondence/Local Address

L A N D M A R K C I T Y / T O W N / V I L L A G E

D I S T R I C T P I N / P O S T C O D E S T A T E / U T C O D E
Country Code Area/STD Code Telephone
14. Telephone Office: Mobile Email
Country Code Area/STD Code Telephone Country Code Area/STD Code Telephone
Telephone Residence: Fax
Alternate Contact No: ____________________________________________________________ Alternate Email: ____________________________________________________________

15. Form 60 PAN No: 16. a Aadhaar Number:

16. b Virtual ID:
17. If you wish to backdate* your policy, please indicate date: *(Backdation can be done up to 180 days within the same financial year only). This option is not applicable for Unit-Linked Insurance Product.
D D M M Y Y Y Y

18. Post Graduate 12th 10th Below Others

Educational Qualification: and Above Graduate Diploma Illiterate
Pass Pass 10th Pass (Specify)
19. Occupation: S- Service ( Private Sector Public Sector Government Sector Others)
O- Others ( Professional Self Employed Retired Housewife Student) B- Business X- Not Categorised

PNB MetLife India Insurance Company Limited

Registered office: Unit No. 701, 702 & 703, 7th Floor, West Wing, Raheja Towers, 26/27 M G Road, Bangalore -560001, Karnataka. IRDA of India Registration number 117.
CI No. U66010KA2001PLC028883 Call us Toll-free at 1-800-425-6969, Website: www.pnbmetlife.com, Email: [email protected] or write to us 1st Floor, Techniplex -1,
Techniplex Complex, Off Veer Savarkar Flyover, Goregaon (West), Mumbai - 400062. Phone: +91-22-41790000, Fax: +91-22-41790203
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20. Occupation Details: 21. Additional KYC : 22. Income Proof: 23. Age Proof*:
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Name of additional documents submitted if Proposed Owner is a Trust or Foundation OR Type of Cover is selected as Employer-Employee/ General Partnership/ Key Partnership/ Key Person.
Name & Address of the Organization/Business Nature of Business Exact Nature of Duties Designation Years of Annual Gross Income (in Rs.) *In case of Non Standard Age
Service/Business Proof like Voter ID Card,
Ration Card, etc. extra of
Rs.2.50 per thousand sum
assured will be charged

24. Identity Proof: (Certified copy of anyone of the following Proof of identity [Pol] needs to be submitted)
A- Passport No. Passport Expiry Date D D M M Y Y Y Y B- Voter ID Card
C- PAN No. D- Driving License Driving License Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar) F- NREGA Job Card Z- Others (any document notified by the central government)
S- Simplified Measures Account - Document type code Identification No.
Purpose of Insurance: Planning for Child's future Protection Saving Key person Others
25. Retirement Gift of Life (Specify)
26. Do you wish to receive your policy document through electronic mode? You may not get the physical policy document if you opt to receive policy document through electronic mode. Yess No

B. Proposed Holder (To be filled if different from the Proposed Insured and all FIELDS are mandatory)
1. Name (Mr./Mrs./Ms./Dr./Master/Other): F I R S T M I D D L E L A S T
(Same as ID Proof)
2. Maiden Name (Ms./Dr./Other): F I R S T M I D D L E L A S T

3. Father’s Name (Mr./Dr./Other): F I R S T M I D D L E L A S T

4. Mother’s Name (Ms./Mrs./Dr./Other): F I R S T M I D D L E L A S T

5. Spouse Name (Mr./Mrs./Dr./Other): F I R S T M I D D L E L A S T

6. Date of Birth: D D M M Y Y Y Y 7. Place of Birth: (Include Country

Name) PROPOSED
8. Gender: M-Male F- Female T- Transgender Married 9. Marital Status:
Unmarried Others (Specify) ________________ HOLDER
10. Relationship with the Proposed Insured:_________________________________________________________________ Paste here
11. Citizenship: IN- Indian Others-ISO 3166 Country Code 12. Are you Tax resident of any other country other than India Yes No (do not pin or staple)
[If Yes, please fill up FATCA/ CRS questionnaire and fill point 14 (iii)] * A recent passport size
13. Resident Individual Non Resident Indian Foreign National _____________________ photograph (not more
Residential Status: Person of Indian Origin COUNTRY NAME
than 6 months old)
14. (i) Current/Permanent/Overseas Address: (Certified copy of anyone of the following Proof of Address [PoA] needs to be submitted)
Address Type: Residential/Business Residential Business Registered Office Unspecified
Address Proof: Passport Driving License UID (Aadhaar) Voter Identity Card NREGA Job Card Simplified Measures Account – Document Type Code
Others ___________________ Please provide the number for the proof submitted ____________________________________

L A N D M A R K C I T Y / T O W N / V I L L A G E

D I S T R I C T P I N / P O S T C O D E S T A T E / U T C O D E

(ii) Correspondence/Local Address

Same as Current/Permanent/Overseas Address (In case of multiple Correspondence/Local Address, please fill annexure A1)

L A N D M A R K C I T Y / T O W N / V I L L A G E

D I S T R I C T P I N / P O S T C O D E S T A T E / U T C O D E
(iii) Address in the Jurisdictions details where applicant is Resident Outside India for tax purposes
Same as Current/Permanent/Overseas Address Same as Correspondence/Local Address

L A N D M A R K C I T Y / T O W N / V I L L A G E

D I S T R I C T P I N / P O S T C O D E S T A T E / U T C O D E
Country Code Area/STD Code Telephone
15. Telephone Office: Mobile Email
Country Code Area/STD Code Telephone Country Code Area/STD Code Telephone
Telephone Residence: Fax
Alternate Contact No: ____________________________________________________________ Alternate Email: ____________________________________________________________

16. 17. a Aadhaar Number:

Form 60 PAN No:
17. b Virtual ID:
18. Educational Qualification Post Graduate Diploma 12th 10th Below
and Above Graduate Illiterate Others (Specify)
Pass Pass 10th Pass
19. Occupation: S- Service ( Private Sector Public Sector Government Sector Others)
O- Others ( Professional Self Employed Retired Housewife Student) B- Business X- Not Categorised
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20. Occupation Details: 21. Additional KYC : 22. Income Proof: 23. Age Proof:
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Name of additional documents submitted if Proposed Owner is a Trust or Foundation OR Type of Cover is selected as Employer-Employee/ General Partnership/ Key Partnership/ Key Person.

Name & Address of the Organization/Business Nature of Business Exact Nature of Duties Designation Years of Annual Gross Income (in Rs.)
Service/Business

24. Identity Proof: (Certified copy of anyone of the following Proof of identity [Pol] needs to be submitted)

A- Passport No. Passport Expiry Date D D M M Y Y Y Y B- Voter ID Card

C- PAN No. D- Driving License Driving License Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar) F- NREGA Job Card Z- Others (any document notified by the central government)
S- Simplified Measures Account - Document type code Identification No.

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 C. Nominee details (To be filled if Proposed Insured and Proposed Holder are the same) and Appointee details - To be filled only if the Nominee is a minor. (The Appointee must not be
the Proposed Insured)

Nominee details
1. Name (Mr./Mrs./Ms./Dr./Master/Other) F I R S T M I D D L E L A S T

2. Date of Birth D D M M Y Y Y Y 3. Gender Male Female Transgender 4. Marital Status Single Married Divorced Widowed

5. Nationality: Indian Non-Resident Indian Person of Indian Origin Foreign National________________________________________(Country Name)
(If Non-Resident Indian or People of Indian Origin or Foreign National, please mention the country you reside in the space provided above and complete NRI/PIO/Foreign National questionnaire)
6. Relationship with the Proposed Insured ___________________________________ 7. % Nominee Share** % **In case of more than one nominee, please fill respective share of
nomination in multiple nominee form
Appointee details
1. Name (Mr./Mrs./Ms./Dr./Master/Other) F I R S T M I D D L E L A S T
2. Date of Birth D D M M Y Y Y Y 3. Gender Male Female 4. Marital Status Single Married Divorced Widowed

5. Nationality: Indian Non-Resident Indian Person of Indian Origin Foreign National________________________________________(Country Name)
(If Non-Resident Indian or People of Indian Origin or Foreign National, please mention the country you reside in the space provided above and complete NRI/PIO/Foreign National questionnaire)
6. PAN No. 7. Signature Accepting the Appointment 8. Relationship with Nominee

D. Details of Insurance policies & previous Proposal forms of the proposed insured with PNB MetLife India Insurance company and other life insurance companies. Please do specify in
Type of Policy column below if information includes details of existing standalone Cancer and/or Heart/Cardiac products

In case the Proposed Insured is a minor/student provide the following details for the entire family. In case Proposed Insured is house wife provide the following details of husband.
Relationship with Existing Policy SA/ In force/ lapsed/in case Acceptance terms (Std./
Proposed Insured Name of the Policy/Proposal Face Amount (Rs.) Annualised Year of of revival, date of with extra/ postponed/ declined/
Type of Policy
(Self, family member) Insurance Company Number Base +Term Rider Premium Issue revival/pending withdrawn/restricted benefits)

E. Medical Details & Family History of the Proposed Insured

1. Height in cms or Ft. Inches Weight in Kgs or Pounds

2. Family History Living Deceased

Relation to Details of present health and full particulars of any major illness (Heart, diabetes, stroke, hypertension,
Proposed Insured Age raised cholesterol, cancer, multiple sclerosis, Alzheimer, Parkinson or any hereditary disease) Age Cause of Death

Father

Mother

Brothers/Sisters

Spouse

Children

3. Medical Details
Have you ever had symptoms of, been treated for, been advised to receive treatment or have undergone any investigations for any of the following. (The below conditions are provided as examples only and would
request you to disclose all disorders, disease or other health conditions, which are, or might be relevant. If answer for any of the questions in this section is “Yes” please provide all medical reports, if available.)
Yes No Yes No
1. High Blood Pressure, Chest Pain, Angina, Heart Attack or any other ailment 11. Depression, Stress, Anxiety, Attempt to Suicide or any other Psychological or
pertaining to the Heart or Circulatory System? Emotional Disorder or Nervous Breakdown or Mental Illness or symptoms of
the same?
2. Seizures, Stroke, Paralysis, Epilepsy, Parkinson's, Multiple Sclerosis or any
12. Have you or your spouse ever been tested of or received any medical advice,
other Disorder of the Brain or Nervous System?
counseling or treatment in connection with HIV/AIDS or Hepatitis B/C or any
Sexually Transmitted Diseases?
3. Tuberculosis, Asthma, Bronchitis, Avian Flu, Shortness of Breath or any other
Respiratory Disorder? 13. During the past five years,

4. Cancer, Tumour, Cyst, Leukemia, Growth, Lump or other Malignancy? (a) Have you Consulted any doctor or health practitioner for illness lasting for
more than 4 days except for fever, common cold or cough?
5. Any Kidney, Liver, Bladder Disorder or Prostate Disease, Blood/Protein in
(b) Have you Undergone ECG, x-rays, blood test or other tests?
Urine?
(c) Have been admitted/advised to be admitted to any hospital or any other
6. Ulcers or any Stomach or Intestinal Disorder? medical facility?

7. Diabetes, Thyroid or any other Gland Related Disorders?

14. Do you have any physical deformity/defect or any congenital condition?
8. Any Disorder related to Ear, Nose and Throat?
15. Has there been drastic weight loss or weight gain (> =5 Kgs) in the past year?
9. Any Back, Arthritic, Joint or Bone Disorders or Skin Lesion?
16. Have you undergone or been advised to undergo surgery of any kind or any
10. Do you have Anaemia, Leukaemia or any other blood related disorders major organ transplant?

4. Have you been or are you suffering from any other illness, injury, disease condition or have undergone medical examination not mentioned in the above questions due to which you have abstained from
work for more than 7 days? If yes, please provide details of the illness and the treatment /medication taken or being taken.
For each ‘Yes’ in point 3 please identify the question and provide full details, conditions, dates, duration and results. Kindly provide the full name and address of Doctor/ Hospital/ Clinic etc.
Question No. Details

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5. For Female Proposed Insured Only

1) Are you Pregnant? Yes No If yes, please mention current months of pregnancy. Less than or equal to 6 months More than 6 months
If any complications relating to pregnancy please give details.

2) Have you delivered, undergone caesarian section, had any abortion or miscarriage? Yes No If yes, please mention the period elapsed since the last occasion
In last 3 months 3 to 6 months More than 6 months

3) Have you suffered / are suffering from any disorder of the breast or reproductive organs? Yes No If yes, please provide details
6. Additional medical details - Please fill only when 'PNB MetLife Mera Heart and Cancer Care'- Cancer Cover OR Heart and Cancer Cover is chosen

1. Have you suffered from or been advised investigation/investigated or been Yes No 4. Have you suffered from or been investigated for any of the following in the Yes No
treated for any form of Cancer, sarcoma, tumor, or pre-cancerous conditions past 12 months?
for example Barrett's esophagus, atrophic gastritis, cervical dysplasia, (a) Recurrent cough, hoarseness of voice, or difficulty in swallowing for a
leukoplakia? Continuous period of 15 days?
(b) Any persistent loss of blood or unusual discharge from any part of the body?
2. Are you suffering from or ever suffered from Hepatitis B, Hepatitis C, Liver (c) Weight loss more than 5kg within 6 months?
disease due to alcohol, Barrett's Oesophagus, Crohn's Disease, Peptic Ulcer,
Ulcerative Colitis? (d) Any ulceration, growth, nodule, cyst or lump in any part of the body?
5. Are you suffering from or ever suffered from HIV/AIDs, Chronic
3. Have you had abnormal findings in any of the listed investigations in the last 6 Glomerulonephritis, Chronic Kidney Disease, Polycystic Kidney Disease,
months - Ultrasound Endoscopy, Colonoscopy CT SCAN,MRI, Biopsy, PAP Anaemia?
Smear, Mammography, Blood test for cancer diagnosis (Tumor Marker) 6. Are you suffering from or ever suffered from Fatty liver, Gastritis, Gastro-
Oesophageal Reflux?
F. Life Style & Personal Details of the Proposed Insured
1. Life Style Information:
1) Have you smoked or consumed tobacco or nicotine products in any form* in the last 5 years? (*Tobacco product includes but not limited to Cigarettes, Bidis, Cigars,
chewable tobacco like Gutkha, flavored Pan masala etc.) Yes No
2) Please give the following details:
Substance If stopped consuming, state date
Yes No Consumed As Quantity For No. of months since when you stopped
Consumed

No. of sticks/day Years Months

Pipe Cigar Cigarettes Beedi
Tobacco
Gutkha No. of packets/day Years Months

Alcohol Beer Wine Liquor Pint / ml per week Years Months

Narcotics / Drugs Marijuana Cocaine Addictive Drugs Years Months

3) Is your occupation associated with any specific hazards (E.g. Mines, Explosives, Yes No If yes, please complete Aviation Questionnaire. (Please tick “No” if you are a
Corrosive Chemicals and HTV Drivers, etc), please complete the respective fare-paying passenger in domestic/international airline)
Occupation Questionnaire? Yes No
4) Are you employed in Armed, Para Military or Police Force, if Yes, please complete Yes No 7) Do you engage in Automobile or Motor-cycle Racing, Skin or Scuba Diving,
Skydiving or Professional Sports? If yes, please complete respective
Armed Services Questionnaire? Avocation Questionnaire.
5) Have you ever been convicted of a criminal offence or do you have any criminal Yes No 8) Are you (PI/PO/PP) or your family member/close associate is politically
case or charge pending against you? Yes No
6) Have you flown in the last two years or do you expect to fly in future either as a exposed person (PEP*). If yes please fill the PEP Questionnaire.
Yes No 9) Is the Proposed Holder/Nominee/Premium Payer a Trust, charity, NGO or Yes No
Student Pilot, Pilot, Crew Member Passenger in a Non-Commercial/ Personal /
Chartered Flight? organisation receiving donations?
* Individuals who are or have been entrusted with prominent public functions domestically or by a foreign country , which may include Heads of State or of government, senior politicians (Members of
Political parties contested in elections of Local bodies/Legislature/Parliament or Nominated), senior government (All Secretary levels), judicial or military officials (Ranks Equivalent to Major and
above), senior executives of state owned corporations, important political party officials. Individuals who are or have been entrusted with a prominent function by an international organization, refers to
members of senior management or individuals who have been entrusted with equivalent functions, i.e. directors, deputy directors and members of the board or equivalent functions.
Family members are individuals who are related to a PEP either directly (consanguinity) or through marriage or similar (civil) forms of partnership.
Close associates are individuals who are closely connected to a PEP, either socially or professionally.

G. Product Details
1.
Product Name Policy Term Premium Payment Term Modal Premium Basic Sum Assured Premium Multiple

Plan/ Benefit Option: __________________ Accumulation of Survival Benefit payout: Yes No Cover Option:___________ Lump Sum %:_______ Build-Up option: Yes No
Income Mode: ________________ Date of Benefit Payout: dd/mm Return of Premiums: Yes No Other benefit / option: ___________ Cash Bonus option: Yes No
Joint life cover: Yes No (if Joint life cover is chosen, then please complete Joint Life Questionnaire) Sum Assured of Joint Life : Rs.___________________

Frequency of premium payment: Single Monthly Quarterly Half-yearly Yearly Annualised Premium Amount (Rs.):
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** Preferences for Renewal Premium Payment Mode: Cash^ Cheque /DD Online Payment^^ Direct Debit/ACH* PSP PNB-Auto Debit
J&K Bank Auto Debit KBL Auto Debit Others (Specify) ___________________________ *Please fill in the relevant Standing Instruction Form. ^All Premium payment in cash
has to be made directly at our nearest branch. Our agents are not authorized to collect the premium in cash. ^^Payment can be made through Debit/ Credit Card/ NEFT.

Rider Name Policy Term Premium Payment Term Premium Amount Sum Assured

**The premium shall be adjusted on the due date even if it has been received in advance & If premium due in one financial year is being collected in advance in earlier financial year, insurers
may collect the same for a maximum period of three months in advance of the due date of the premium.
2. (a) UNIT - LINKED
i. Sum Assured Multiple Chosen: ii. Please select portfolio strategy: Self Managed Auto Rebalancing Systematic Transfer Life-stage

iii. Please choose the allocation proportion:

Bond Balanced Premier Mid Cap CREST
Preserver II Protector II Balancer II Multiplier II Virtue II Flexi Cap Multiplier III Liquid Fund Opportunities Opportunities Multi-cap Total
Fund Fund Fund Fund Fund
100%
If Auto Rebalancing Strategy is chosen, then allocation must only be in Flexi Cap and Protector II. Minimum allocation in any fund has to be 20%
iv. Choose rebalancing event (as% of Fund Value): 10% 15% 20% 25% v. Choose Stop Loss option (as% of Nav): 10% 15% 20% 25% 30%
(b) TRADITIONAL
(a) Incase of PNB MetLife Monthly Income Plan-10 Pay Choose the Monthly Regular Income (b) Lump - Sum Option Guaranteed Regular Income
(c) For MetLife Retirement Savings Plan only:
(1) Which Annuity Option* would you like to choose: _______________________ (2) Frequency of Annuity Payout: ______________________________________
*Please ask your advisor to explain your annuity options. You have the option to modify your choice in future till 90 days before the vesting date by intimating the same to PNB MetLife.

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 H. Additional Information

Crossed Cheque## Online Payment~

#
1. Details of Initial Deposit Type of Deposit Bank Draft Cash PNB-Auto Debit J&K Bank Auto Debit
Instrument No. Instrument Date : ________________ Amount in (Rs.) ____________ Name of the Bank & Branch : __________________________
2. Premiums will be paid by Proposed Insured Proposed Holder Others* (Specify)_______________________ * Please fill third party declaration form
If other, please provide the following details. Name Relationship to Proposed Holder Annual Income of the Premium Payor

3. Form 60 of Third party PAN No. of Third party: 4. Account type of PO Saving Current NRE NRO

5. ^Account No. of PO: MICR Code: IFSC Code:

PO bank & Branch Name : _________________________ #
Cheque/DD made payble to “PNB MetLife India Insurance Company Limited. Proposal/Policy no_________” Details will be used for all payouts by PNB MetLife
Cheque subject to realization. ~Payment can be made through Debit/ Credit Card/ NEFT. ^Bank Proof (Pre-Printed Cancelled Cheque / Bank Account Statement) to be mandatorily submitted.
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I. E-Repository Details

1. If you already have an e-Insurance Account (e-IA) number, kindly provide

2. If you don't have an e-Insurance Account (e-IA), please choose any one of the following

CAMSRep - CAMS Insurance Repository & Services NDML - NSDL Data Management Services limited
KARVY CIRL - Central Insurance Repository Limited

J. Tax Status Questionnaire (To be filed by Proposed Holder)

Do you have an / a:
1. United States citizenship or resident status (resident status applies in the event of the Applicant being an individual or an entity created, incorporated or governed by United States Laws): Yes No
2. US place of birth: Yes No
3. US telephone number: Yes No
4. US residence or correspondence address (including a US PO Box): Yes No
5. Standing instructions to transfer funds to a US account: Yes No
In the event of the any of the questions being answered as Yes, please furnish the following:
1.If the Applicant is subject to United States Federal Income Tax please provide the Applicant's U.S. Tax ID Number(s)* or a W-9
2.If the Applicant is not subject to United States Federal Income Tax please provide a self-certification under perjury, and a Non-US passport or other valid government-issued identification evidencing
citizenship in a country other than the US or such other forms or declarations as may be informed to you by the Company.

IN CASE OF AN APPLICANT NOT CURRENTLY HAVING US INDICIA**, THE APPLICANT AGREES TO INFORM THE COMPANY WITHIN THIRTY (30) DAYS OF THE
APPLICANT'S KNOWLEDGE OF SUCH CHANGE IF THE APPLICANT ACQUIRES US INDICIA.

*If the Applicant(s) is subject to United States Federal Income Tax and fails to provide a U.S. Tax Identification Number to the Company, the Internal Revenue Service requires the Company to
withhold tax from taxable income payments made to the Applicant.

**US indicia (United States Indicia) is defined as any individual or entity who exhibits any of the following:
1. United States citizenship or resident status (applicable to an entity by virtue of being created, incorporated or governed by United States Laws);
2. US place of birth;
3. US telephone number;
4. US residence or correspondence address (including a US PO Box); or
5. Standing instructions to transfer funds to a US account.

RISK PROFILE:
In addition to the insurance coverage, the Proposed Insured/Proposed Holder has the ability to control the allocation of premium, after deduction of charges into various funds, except in case Automatic
option is chosen. In order to understand more about your risk tolerance levels, the Proposed Insured/Proposed Holder can discuss with PNB MetLife sales representative and use the risk profile
questionnaire to select the ideal fund option/portfolio. The final decision is up to the Proposed Insured/Proposed Holder.

DECLARATION & AGREEMENT

DECLARATION:
I/We have read this proposal or got read/ explained the proposal, and furnished the information, after fully understanding the contents thereof. I/we have made complete, true and accurate disclosure of all
facts to the best of my/our knowledge and belief and that I/we have not withheld any information. I/We hereby declare, on my/our behalf and on behalf of the person proposed to be insured, that the above
statements, answers and/or particulars given by me/us are true and complete in all respects to the best of my/our knowledge and that I/we am/are authorized to propose on their behalf. I/We understand that
the information provided by me/us form the basis of the insurance policy and that the policy is subject to the Board approved underwriting policy of PNB MetLife India Insurance Company Limited ('PNB
MetLife') and that the cover will come into force and effect only after full receipt of the premium chargeable and upon issuance of the policy.

I/We declare that I/we consent to the Company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/proposer or from any past or present
employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an proposal for insurance on the person to
be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement. I/We authorize the Company to share information pertaining to my proposal including the medical
records of the insured/proposer for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority. I/We hereby further consent, and
authorize, PNB MetLife to use and disclose any of the personal and sensitive information of the insured/ proposer collected or available with PNB MetLife (whether contained in this proposal or obtained
otherwise) which may include KYC documents to any individual/organisation/entity associated or affiliated with or engaged by PNB MetLife, including reinsurers, claim investigative agencies, vendors
and industry associations/federations, for the purpose of processing/underwriting this proposal and/or providing subsequent services which will include services arising out of the insurance contract,
including claims settlement.

Optional Voluntary Declaration and Non-Mandatory:

If the customer has voluntarily provided his/her Aadhaar details along with this proposal, the below consent/undertaking/authorisation becomes applicable.

I/We provide my/our below consent in accordance with the Aadhaar (Targeted Delivery of Financial and Other Subsidies, Benefits and Services) Act, 2016, and regulations framed thereunder for: (a)
collecting, storing and using, (b) validating/authenticating, and (c) updating my/our last 4 digits of Aadhaar number.
I/We hereby state that I/We am/are voluntarily interested in conducting the authentication of my/our Aadhaar number and do hereby consent to provide my/our Aadhaar number, Virtual ID, Biometric
and/or One Time Pin (OTP) data for Aadhaar based authentication for the purposes of availing of the policy from PNB MetLife and receiving its services. I/We understand that the Biometrics and/or OTP
I/We provide for authentication shall be used only for authenticating my /Our identity through the Aadhaar Authentication system for rendering the services from PNB MetLife and for no other purposes.
I/We understand that PNB MetLife shall ensure security and confidentiality of my/our personal identity data provided for the purpose of Aadhaar based authentication as required under the applicable laws
and regulatory provisions. I/We understand that PNB MetLife shall retain/store the last four digits of my/our Aadhaar number or any document or database containing my Aadhaar number only for the
purpose of the rendering its services to me/us as mentioned above herein and for the time period no longer than necessary for the purpose specified hereinabove. I/We are aware that PNB MetLife has a
mechanism for the redressal of my/ our grievances, if any, in respect of the usage and storage of my/our personal information.

AGREEMENT:
1. I/We do hereby agree that: 1.My/Our answers and/or statements provided herein and this declaration shall form the basis of policy issued by PNB MetLife.
2. I/We do hereby agree that information provided by me/us shall be the basis of insurance contract between me/us and PNB MetLife.
3. If, after submission of this Proposal and before issue of the policy (i) If there are any adverse circumstances connected with the general health of the Proposed Insured/Proposed Holder or (ii) If an
proposal for insurance on the life of the Proposed Insured/Proposed Holder made to any other insurance company or an proposal of revival, has been withdrawn or dropped or accepted at an increased

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premium or on terms other than as originally proposed or (iii) if there is any change in my/our occupation or financial position, I/we shall forthwith intimate the same to PNB MetLife in writing to reconsider
the terms of acceptance of this Proposal.
4. If there is any suppression or mis-representation of material information or any untrue statement contained in the information provided hereinabove or in case of fraud or any material omission happens
on my/our part in providing the information as required to be provided per item number three above, the insurance contract entered basis this Proposal shall be treated as null and void in accordance with the
provisions of Section 45 of the Insurance Laws (Amendment) Act, 2015 and as amended from time to time.
5. The payment made along with the proposal is a deposit with PNB MetLife to be adjusted towards premium in the event of acceptance of the risk sought to be insured by me/us. Unless accepted, no risk
shall attach to PNB MetLife. In the event that the Proposal is found acceptable, PNB MetLife shall be entitled to issue the policy commencing from any date subsequent to the date of submission of the
Proposal by me/us. I/We agree to undergo all medical tests required by PNB MetLife as per its guidelines, including HIV-Elisa Test.
6. I/We hereby declare that the money used by me/us to pay the premium under this Proposal has not been derived from any criminal or illegal activity or any unknown sources.
7. I/We hereby acknowledge that the information provided under this Proposal will be used for the purpose of underwriting this Proposal and for providing policy related services, in the event of the risk
being accepted by PNB MetLife.
8. I/We understand that any premium if paid by cash has to be paid only in PNB MetLife branches. Suvidha outlets and other authorized cash collection agencies against an official Receipt and not to PNB
MetLife's Insurance Agent/Broker/Corporate Agent. If it is paid to Insurance Agent/Broker/Corporate Agent for depositing with PNB MetLife, then the Insurance Agent/Broker/Corporate Agent for this
purpose is acting as my/our authorized representative and not that of PNB MetLife and PNB MetLife shall not be liable for any loss incurred by me/us while doing so.
9. I/We further agree and consent to PNB MetLife receiving my/our updated address from CERSAI (which will happen on my/our updating the new address in my/our account maintained with any Bank or
other financial Institution) and update the new address in my/our policy/ies with PNB MetLife. I/ We hereby agree and consent PNB MetLife to send future communication regarding my/ our policy and
other services through its preferred communication channel (including but not limited to SMS, E-mail and physical letters). Such communication made by the Company shall override the Do not Disturb
(DND) registrations, if any, made earlier or anytime herein after by me.
10. The policy will lapse in case the premium is not paid as per the payment terms opted.
11. I/We also understand that the premium and the benefits payable under the Policy are subject to variation basis the change in applicable taxation and other relevant in accordance to applicable laws from
time to time.

Signature / Left Thumb Impression of the Proposed Holder Signature / Left Thumb Impression of the Proposed Insured (If different from Proposed Holder)

Name of the Proposed Holder: Name of Proposed Insured

Name of Witness Signature of the Witness

(Witness should not be related to the
Proposed Insured / Proposed Holder)

Address of witness

Date Place

DECLARATION IN CASE OF VERNACULAR (Can not be signed by sales person or nominee)

Declaration by the person filling in the Proposal. (In case the Proposal is filled up / signed in a language different from that of the Proposal form.)
I hereby declare that I have fully explained the contents of the Proposal form and all other documents incidental to availing the insurance from PNB MetLife to the Applicant in the language understood by him/her. The
same have been fully understood by him / her and the replies have been recorded as per the information provided by the Applicant and the replies have been read out to, fully understood and confirmed by the Applicant.

Declarant's Name Address

The content of the form and documents have been fully explained to me and that I have fully understood the same.

Date Place Signature of Declarant Signature/ Left Thumb Impression of

Proposed Holder/ Proposed Insured

DECLARATION IN CASE THE APPLICANT IS ILLITERATE (Can not be signed by sales person or nominee)

In case the Applicant is illiterate, a person of standing, unconnected with PNB MetLife, but whose identity can easily be established, should give the following declaration after attesting left thumb
impression of the Applicant

I hereby declare that I have explained the contents of this Proposal in _____________________________ language to the Applicant. The same have been fully understood by him/her and replies have been recorded as
per the information provided by the Applicant and the replies have been read out to and fully understood by and confirmed by the Applicant. The Applicant has affixed his/her left thumb impression in my presence.

Declarant's Name Address

Date Place Signature of Declarant Signature/ Left Thumb Impression of Proposed Holder/ Proposed Insured

Section 45 of the Insurance Act, 1938 :

1. No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy i.e. from the date of issuance of the policy or the date of
commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
2. A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date
of the rider to the policy, whichever is later, on the ground of fraud; provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of
the insured, the grounds and materials on which such decision is based. For the purposes of this sub-section, the expression 'fraud' means any of the following acts committed by the insured or by his
agent, with the intent to deceive the insurer or to induce the insurer to issue a life insurance policy:
a. The suggestion, as a fact of that which is not true and which the insured does not believe to be true;
b. The active concealment of a fact by the insured having knowledge or belief of the fact;
c. Any other act fitted to deceive; and
d. Any such act or omission as the law specifically declares to be fraudulent.

Mere silence as to facts likely to affect the assessment of risk by the insurer is not fraud, unless the circumstances of the case are such that regard being had to them, it is the duty of the insured or his
agent, keeping silence to speak, or unless his silence is, in itself, equivalent to speak.
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.

STATUTORY WARNING as per Section 41 of the Insurance Act, 1938:

(1) 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 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.

(2) Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.

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