COMMON PROPOSAL FORM (CPF) V6

APPLICATION NO.:

PROPOSER (to be filled only if different from the life to be insured) /

PARTICULARS LIFE TO BE INSURED
SECONDARY LIFE INSURED
1.14 b) IF SELF-EMPLOYED Trading Manufacturing Professional Trading Manufacturing Professional
(please tell us the type of organization)
Others (please specify) Others (please specify)

1.14 c) WORK DETAILS a) No. of Years in Service b) Designation c) Nature of Work a) No. of Years in Service b) Designation c) Nature of Work
(present employment)

d) Nature of Business of the Organization d) Nature of Business of the Organization

1.15 C/o or S/o or W/o

PERMANENT
RESIDENTIAL House/Flat No./Society
ADDRESS
Street/Lane/Mohalla
Landmark
Area/Location
Village/Taluka/Tehsil
City/District

State Pin Pin

1.16 C/o or S/o or W/o
CURRENT
RESIDENTIAL House/Flat No./Society
ADDRESS
(If different Street/Lane/Mohalla
from
Permanent Landmark
Residential Area/Location
Address)
Village/Taluka/Tehsil

City/District

State Pin Pin

1.17 Name
OFFICE
ADDRESS
(Company
name and Street/Lane
full address
of present Landmark
employer/ Area/Location
last employer
for retired
individuals)
City/District

State Pin Pin

1.18 PREFERRED MAILING ADDRESS Permanent Residential Current Residential Office Permanent Residential Current Residential Office

1.19 TELEPHONE NUMBER Residence Residence

(with STD Codes)
Office Office

Mobile Mobile

1.20 E-mail ID

1.21 IT ASSESSEE Yes No Yes No

1.22 PERMANENT A/C NO. (PAN) Enclosed Yes No Enclosed Yes No

1.23 IF PAN NOT AVAILABLE Applied for Not Applied for Applied for Not Applied for

1.24 RELATIONSHIP TO
LIFE TO BE INSURED NOT APPLICABLE

1.25 TOTAL EXISTING LIFE COVER

(excluding this proposal) (in `) PLEASE REFER TO QUESTION NO. 9

1.26 Additional Details - Indicator for a) Place and Country of Birth a) Place and Country of Birth
Residence / Tax status Place Place

Country Country

b) Are you a citizen of any other country also Yes No b) Are you a citizen of any other country also Yes No
(dual / multiple) (dual / multiple)
c) Are you a resident (for tax purposes) Yes No c) Are you a resident (for tax purposes) Yes No
of any other country other than India of any other country other than India
d) Do you hold a green card of US or any Yes No d) Do you hold a green card of US or any Yes No
similar card for any other country similar card for any other country
If answer to any / all of the above is yes, please do fill all the details If answer to any / all of the above is yes, please do fill all the details
in the Insurance FATCA Declaration in the Insurance FATCA Declaration
 APPLICATION NO.:

1.27 Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (eIA) of an Insurance Repository? Yes No
1.28 If you have an eIA, provide details a) Name of Insurance Repository

b) eIA No: c) Name as appearing in eIA:

1.29 If you do not have an eIA, would you like to open an account? Yes No
If Yes, choose any one Insurance Repository:
CAMS Repository Services Limited NSDL Data Management Limited Karvy Insurance Repository Limited Central Insurance Repository Limited

2. ADDITIONAL INFORMATION OF THE LIFE TO BE INSURED AND PROPOSER

PROPOSER (to be filled only if different from the life to be insured) /

PARTICULARS LIFE TO BE INSURED
SECONDARY LIFE INSURED
Passport Voter’s Identity Card Ration Card Passport Voter’s Identity Card Ration Card
2.1 PROOF OF IDENTITY
PAN Card Driving Licence Others (ple. specify) PAN Card Driving Licence Others (ple. specify)

2.2 PROOF OF PERMANENT Telephone Bill Electricity Bill Passport Telephone Bill Electricity Bill Passport
RESIDENCE (in case both are different,
proof of Permanent Residence Proposer only.) Driving Licence Voter’s Identity Card Others (ple. specify) Driving Licence Voter’s Identity Card Others (ple. specify)

2.3 PROOF OF CURRENT Telephone Bill Electricity Bill Passport Telephone Bill Electricity Bill Passport
RESIDENCE (in case both are different,
proof Current Residence of Proposer only.) Driving Licence Voter’s Identity Card (ple. specify) Driving Licence Voter’s Identity Card (ple. specify)
Others Others
Salary Business Income Inheritance Salary Business Income Inheritance
2.4 SOURCE OF EARNINGS
Others (please specify) Others (please specify)

2.5 PROOF OF INCOME (where sum of IT Returns Employer’s Certificate Audited P/L Accts. IT Returns Employer’s Certificate Audited P/L Accts.
annualized premiums across all policies with KLI
[including at proposal stage] is ` 1 Lakh or more) Others (please specify) Others (please specify)

2.6 GSTIN No.

2.7 ABHA No.
2.8 OTHER DETAILS PROPOSER (to be filled only if different from the
LIFE TO BE INSURED
life to be insured) / SECONDARY LIFE INSURED
a) Do you have any history of conviction under any criminal proceedings in India or abroad? Yes No Yes No
b) Are you a Politically Exposed Person (these are the people who hold prominent public function viz. Heads/Ministers Yes No Yes No
of Central or State Govt., Senior Politicians, Senior Govt., Judicial or Military Officials, Senior Executives of Govt.
companies, Important Political Party Officials, and immediate family members of above persons)?
c) 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 Yes No
d) Are you currently engaged in or intend to take part in any hazardous hobbies / activities which would increase the risk
of any injury or illness to you? Yes No Yes No

e) If your answer is 'Yes' to any of the above questions kindly give details:

3. PARTICULARS OF THE PLAN PROPOSED

Premium Payment Policy Term Sum Assured Modal

3.1 Name Of Plan / Option / Rider
Term (yrs.) (yrs.) (`) Premium (`)
Basic Plan
Rider / Optional
Benefits Details
(please fill the Life Guardian /
Spouse Addendum where
applicable)

*Note: ECS/ SI is Mandatory for Monthly Premium Frequency GOODS AND SERVICES TAX AND CESS ON MODAL PREMIUM
TOTAL PREMIUM (ROUNDED OFF TO THE NEAREST RUPEE)

3.2 Plan Option 3.3 Payout Option 3.4 Step Up Option

3.5. Bonus Option 3.6 Deferment Period 3.7 Premium Frequency* 3.8 Accumulation Period
3.9.a.Income Benefit Period 3.9.b.Benefit Payout Frequency 3.10 Survival Benefit Payout Period 3.11 Survival Benefit %
3.12. Spouse Name Spouse Gender Spouse DOB D D M M Y Y Y Y Spouse Sum Assured
3.13 Utilize the Guaranteed Loyalty Additions to pay the due premiums Yes No
 Strategy Self Managed Strategy Systematic
Funds Money Dynamic Kotak Mid Cap Kotak Kotak Nifty 500 Switching
Classic Frontline Balanced Dynamic Dynamic
Market Floating Advantage Fund Manufacturing Multicap Momentum Strategy Total
Opportunities Fund Equity Fund Fund Bond Fund Gilt Fund (SSS)*
Fund Rate Fund Fund Quality 50 Index Fund
Allocation % 100%
 APPLICATION NO.:

7.14 NATIONALITY Indian NRI / PIO 6

Others (Pls specify) Indian NRI / PIO 6 Others (Pls specify)
7.15 GENDER Male Female Male Female
7.16 DATE OF BIRTH D D M M Y Y Y Y D D M M Y Y Y Y

7.17 C/o or S/o or W/o

CURRENT
House/Flat No./Society
RESIDENTIAL
ADDRESS Street/Lane
Landmark
Area/Location
Village/Taluka
City/District
State Pin Pin
7.18 RELATIONSHIP TO LIFE TO BE
INSURED
5
Applicable only if Proposer and Life to be Insured are the same.
6
Please fill in the NRI / PIO Questionnaire.

8. PARTICULARS OF APPOINTEE 7/ LEGAL GUARDIAN

8.1 TITLE SURNAME FIRST NAME MIDDLE NAME

8.2 CLIENT ID (As policyholder 8.3 DATE OF BIRTH D D M M Y Y Y Y 8.4 RELATIONSHIP TO NOMINEE
or as Nominee/Appointee/Trustee etc.)

8.5 CURRENT RESIDENTIAL ADDRESS

Village / District Land Mark

City State Pin

8.7 Gender Male Female Transgender
8.6 Signature/Thumb Impression of the Appointee

7
Where the Nominee(s) is/are a minor.

9. DETAILS OF LIFE INSURANCE POLICIES HELD / PROPOSALS APPLIED FOR BY THE LIFE TO BE INSURED
9.1 Do you have any existing insurance policy (ies) or have you applied for any insurance policy (ies) at any time? Yes (If yes, please give details below) No
9.2 Has any of your policy/ proposal (including riders) ever been rated-up/ postponed/ declined on application or revival? Yes (If yes, please give details below) No

Policy/ Company Name Acceptance Terms (Std./With Whether In Force/Lapsed

Proposal (including Kotak Sum Assured On Death Extra / Postponed / (Mention year of Lapse/
No. Life Insurance) Declined / Not Completed) Revival applied for)

10. PERSONAL HEALTH DETAILS OF THE LIFE TO BE INSURED AND PROPOSER (Details for Proposer to be filled when there is Sum at Risk on Proposer’s life)

PARTICULARS LIFE TO BE INSURED PROPOSER

10.1 HEIGHT cms OR feet inches cms OR feet inches

WEIGHT kgs kgs

10.2A Have you Gained or Lost Weight Yes No Yes No

(more than 10 kgs)in the last 1 year? If Yes, please specify Gain Kgs OR Loss Kgs If Yes, please specify Gain Kgs OR Loss Kgs

10.2B If Yes, please specify reason for

Gain/Loss

10.3 LIFESTYLE DETAILS OF CURRENT USAGE PAST USAGE

THE LIFE TO BE INSURED
Current If YES, form of Since When Average usage Past If YES, form of Past average Reasons for
Usage consumption per day Usage consumption usage per day giving up
Tobacco Cigarette/ Beedi/ Chewing Cigarette/ Beedi/ Chewing Doctor's Advice / Others
Tobacco / Tobacco Tobacco/ Tobacco
Yes No Toothpaste / Pan masala
Yes No Toothpaste / Pan masala
E-cigarette / Hookah E-cigarette / Hookah

Alcohol 8 Yes No Beer/ Wine/ Hard Liquor Yes No Beer/ Wine/ Hard Liquor Doctor's Advice / Others

Any Narcotics Counseling,

Yes No Yes No
(For medical/ recreational purposes) Rehabilitation etc
8
1 unit = half pint beer/1 glass of wine/1 measure of spirits.
 APPLICATION NO.:

11. MEDICAL HISTORY OF THE LIFE TO BE INSURED AND PROPOSER (Details for Proposer to be filled when there is Sum at Risk on Proposer’s life)

11.1 Have you ever suffered from, received/receiving treatment or advice for any of the following conditions, diseases or impairments ? LIFE TO BE INSURED PROPOSER
a) Any cancer, tumour, cyst or unusual growth? Yes No Yes No
b) High blood pressure (hypertension), low blood pressure (hypotension), diabetes, raised cholesterol, stroke, chest pain? Yes No Yes No
c) Any cardiovascular diseases/ disorders, coronary artery disease or any form of heart ailment or rheumatic heart disease etc.? Yes No Yes No
d) Any respiratory diseases/ disorders like asthma, bronchitis, pulmonary TB, lung ailment, etc? Yes No Yes No
e) Any genitourinary diseases / disorders like calculus of kidney/ ureter, acute chronic kidney diseases etc? Yes No Yes No
f) Any digestive system disease/ disorders like ulcers, haemorrhoids, diseases of gall bladder or intestine etc? Yes No Yes No
g) Epilepsy, mental or nervous disorder including depression? Yes No Yes No
h) HIV infection, AIDS related or any other sexually transmitted disease? Yes No Yes No
i) Any other disorder/ disease not mentioned above? Yes No Yes No
11.2 In last 3 years :
a) Have you remained absent from work for at least 10 consecutive days or admitted in hospital for at least 5 consecutive days for any
illness, injury or disorder ? (Please ignore normal pregnancy) Yes No Yes No
b) Have you been treated or are currently undergoing or have been advised treatment from a doctor or specialist or undergone any
cardiological, radiological or pathological tests (excluding routine health check-ups not being follow ups)? Yes No Yes No
11.3 Do you have any physical deformity / disability or mental ailment, blindness, deafness, mutism etc? Yes No Yes No
11.4 Have you ever had persistent fever, unexplained infection or swollen glands in the last one year? Yes No Yes No
11.5 Have you ever been diagnosed with any form of congenital anomalies? Yes No Yes No
11.6 Are you currently receiving or considering receiving medical attention or taking any prescribed drugs? Yes No Yes No
11.7 For Females Lives Only
i) Are you currently pregnant? (If yes, please mention the month of pregnancy)……....................Months Yes No Yes No
ii) Have you ever suffered from or are currently suffering from any complication of pregnancy? Yes No Yes No
iii) Have you ever suffered from or suffering or are currently suffering any diseases of breast/ uterus/ cervix? Yes No Yes No

11.8 If your answer is "Yes" to any of the above questions kindly give details

12. MEDICAL HISTORY OF THE SECONDARY LIFE TO BE INSURED

12.1 Has the child (secondary life assured) ever been diagnosed with or treated / consulted for heart disorder, cancer, nervous or mental disorder, blood disorder, Kidney disorder, congenital birth
abnormalities, developmental disorders, or deformity? Yes No
13. FAMILY HISTORY OF THE LIFE TO BE INSURED
13.1

Father Children
Mother
Sister/
Spouse
Brother(s)
Children

13.2A Have your parents / brothers / sisters / spouse / children ever suffered from or died of heart disease, stroke, high blood pressure, diabetes mellitus, any form of eye disease, cancer, kidney disease or
paralysis, or any hereditary / familial disorders, tuberculosis, or any contagious diseases such as hepatitis, AIDS / HIV etc.? Yes No
13.2B If your answer is 'Yes' to the above question, kindly give details:

14. DECLARATION BY THE LIFE TO BE INSURED, PROPOSER AND IN CASE OF MINOR BY HIS/HER LEGAL GUARDIAN
I/We declare that I/we have answered the questions in the Proposal Form after having fully understood the nature of the questions and the importance of disclosing all
information while answering such questions. I/We also hereby declare that the answers given by me/us to all the questions in the proposal form are true and complete in
every respect and that I/We have not withheld any material information or suppressed any fact. I/We undertake to notify Kotak Mahindra Life Insurance Company Ltd.
(“the Company”) of any change in the state of health of the life to be insured or as to his/her occupation or any decisions about his/her existing policies or proposals Please paste latest
subsequent to the signing of this proposal form and before the acceptance of the risk by the Company. I/We hereby consent to the Company seeking information and self-signed
any reports from any doctor(s) including hospital - who at any time may have attended to me/us concerning anything, which affects my/our physical or mental health. photograph
of the Proposer
I also hereby authorize any organization, institution or individual (including Ayushman Bharat Digital Mission) that has any records or knowledge of my health or
medical history, employment, business, income or other details as may be required or considered relevant to divulge to the Company and the Company to divulge the
same to any organization, institution or individual in connection with this proposal form or the resultant policy. I agree to undergo all medical tests including blood tests
involving HIV antibodies as required by the Company's Underwriting Policy for obtaining the policy. Further I understand that in the event of my being physically examined, the answers given
by me to the medical examiner acting on behalf of the Company, shall be deemed to be duly incorporated in this Proposal Form. In event of this proposal not being converted into a policy, the
Company reserves the right to recover from me medical expenses incurred by the Company.
I/We hereby acknowledge and consent to the collection, storage and sharing of my GSTN for the purpose of compliance with applicable GST rules and regulations and for all the purposes in
connection with the said Proposal or the Policy issued pursuant thereto.
I/We further declare that the statements/submissions made by me/us in this Proposal Form [including any addendum(s) thereto / all declarations, affidavits and other statements] and/or any
information sought for by the Company from any person authorised by me to provide such information, relied upon by the Company to assess the risk on my life under this Proposal Form shall
form a basis of the contract of insurance between me/us and the Company. I/We further agree, in case of fraud/misstatement by me / us, the Policy will be cancelled immediately by the Company
in accordance with the Section 45 of the Insurance Act, 1938 and amendments thereto from time to time.
I/ We hereby agree, consent and authorize Kotak Mahindra Life Insurance Company Limited (“KLI”) to collect and use; any information of the life insured(s) and/ or proposer, including but not
limited to the personal and/ or sensitive personal data or information including KYC document and medical/health information that is contained in this proposal form, available with KLI and/ or
otherwise obtained. I/ We expressly agree, consent and authorize KLI to part/share/ disclose and/ or verify such data and information with any entity including but not limited to statutory/
regulatory/ government bodies, individuals, organizations, entities, reinsurers, auditors, investigation agencies, service providers, industry associations/ federations etc.; in any form or manner as
KLI deems appropriate for the subject life insurance cover and also for providing any other form of service(s) including but not limited to underwriting, issuance of cover, claim investigation/
processing/ payment/ settlement, marketing or promotional communications, value added services, risk management activities, policy servicing etc
 APPLICATION NO.:

I/We understand that the contract will be governed by the provisions of the Insurance Act, 1938, the IRDA Act, 1999 and the Regulations framed there under and that the contract will not commence until
* the Company's written acceptance of this Proposal Form is received by me. In case of the life to be insured being a minor, I further declare and affirm that this proposal of insurance is for the benefit of
the life to be insured.
I/ we hereby confirm that all premiums will be paid from bonafide sources and
no premiums have/will be paid out of proceeds of crime related to any of the Signature/Right Thumb Impression of the Proposer Signature/Right Thumb Impression of the life to be insured
offence listed in Prevention of Money Laundering Act, 2002. (if different from the life to be insured) (or Guardian, if the life to be insured is a minor)

(Applicable for non-tobacco users opting for Kotak e-Term)

I hereby declare, that I have not consumed tobacco in any form (smoking, Place Place
chewing etc.) during the past 12 months and do not have any intention of
consuming tobacco in any form in the future. I am aware that any false Date D D M M Y Y Y Y Date D D M M Y Y Y Y
statement regarding my use of tobacco would render the contract void and lead
to loss insurance cover.
Proposer’s Witness :
Name :
Signature of Witness
Date : D D M M Y Y Y Y

Kotak Mahindra Life Insurance Company Ltd. Witness:

Name :
Signature
Date : D D M M Y Y Y Y

15. DECLARATION FOR ONLINE TRANSACTION RIGHTS:

I have read the terms and conditions of registration on Kotak Life Insurance website - https://www.kotaklife.com and accept them. I
understand that I will have to register on https://www.kotaklife.com to receive my username and password. I agree that all transactions
executed over the website https://www.kotaklife.com under my username and password will be binding on me. I understand that I get
transaction rights for proposal number mentioned above provided my application is accepted by Kotak Life Insurance.
Signature / Right Thumb Impression of the Proposer
Place Date D D M M Y Y Y Y

16. DECLARATION BY THE PERSON FILLING IN THE FORM (Applicable only where form is filled in by a scribe or signed in vernacular languages)

I, ___________________________________________________________ (Full Name) have explained to the Proposer, that the answers to the questions form the basis of the contract of insurance
between the Company and the Proposer. I also confirm that the Life to be Insured has signed / affixed his/ her right thumb impression in my presence.

Address

Village / District Land Mark

City State Pin

Place Telephone No. Relation to Proposer Date D D M M Y Y Y Y

I, the Life to be Insured / Proposer declare that the contents in the proposal form have been fully explained to me

Signature / Right Thumb Impression of (Signature of the Life Advisor/Specified person of Corporate Agent
Signature of the Scribe
the Proposer /Authorised Employee of Broker/ Relationship Officer)

17. DECLARATION BY THE PERSON FILLING IN THE FORM (Applicable only where form is filled in by a representative duly authorised by a person with disability)
I, ___________________________________________________________ (Full Name) have explained to the Proposer, contents with respect to the proposal form, policy documents, terms and
conditions and the eIA.
Address
Village / District Land Mark

City State Pin

Place Telephone No. Relation to Proposer Date D D M M Y Y Y Y

I, the Life to be Insured / Proposer declare that the contents in the proposal form have been fully explained to me

Signature / Right Thumb Impression of (Signature of the Life Advisor/Specified person of Corporate Agent
Signature of the Scribe
the Proposer /Authorised Employee of Broker/ Relationship Officer)

SECTION 41 OF THE INSURANCE ACT, 1938, AS AMEMDED FROM TIME TO TIME STATES: 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 prospectuses or tables of
the insurer.
SECTION 45 OF THE INSURANCE ACT, 1938, AS AMEMDED FROM TIME TO TIME STATES: The provisions of Section 45 of the Insurance Act, 1938 are applicable in the above
contract. Please refer to Section 45 either on our website or contact our intermediary or visit the nearest branch for the full text.
https://www.kotaklife.com/assets/images/uploads/why_kotak/section38_39_45_of_insurance_act_1938.pdf
Note: Proposer is advised to read and understand the product features, benefits & risk factors, structure of charges, terms and conditions of the proposed plan as set forth in the related brochure(s)
available on the Company’s website https://www.kotaklife.com
 APPLICATION NO.:

AGENT'S CONFIDENTIAL REPORT

1. Name of the Life to be Insured / Proposer:

2. Name of the Proposer (In case different from life to be insured) :

LIFE TO BE INSURED PROPOSER
A. How long have you known the Life to be insured / Proposer?
B. How have you been introduced to the Life to be insured / Proposer?
- Long term relationship. No of years
- Cold call
- Referal if yes, Referred by name & contact details

C. When have you last met the Life to be insured / Proposer? ( DD/MM/YY )

D. Have you personally met the Life to be insured / Proposer? Yes No Yes No
E. Are you related to the Life to be Insured and Proposer? (If Yes, pls. mention the relationship & provide an MHR from Sales Manager) Yes No Yes No
F. What is the purpose of taking insurance?
G. Are you satisfied with the Financial condition and income earning capacity of the Life to be insured / Proposer? Yes No Yes No
H. Does the Life to be insured/ proposer have the capacity to pay premium for the entire Premium paying term Yes No Yes No
I. Are you aware of any illness, impairment, adversity or physical or mental abnormality which the Life to be insured is suffering from?
(If yes, give details) Yes No Yes No

J. Have you explained the Product features, benefits & the premium paying term for the plan applied by the client? Yes No Yes No
K. Is there any other additional information you would like to provide? Yes No Yes No
L. Do you recommend the proposal for insurance? Yes No Yes No
Name of the Advisor
(Signature of the Life Advisor/ Specified person of Corporate Agent/
D D M M Y Y Y Y Authorised Employee of Broker/ Relationship Officer)
Dated Place

ACKNOWLEDGEMENT FOR FRESH PROPOSAL*

(Any cash payment should only be made at the cash counter of nearest Kotak Life Insurance branch)
APPLICATION NO.:

Agent ID (Life Advisor/Corporate Agent/ Date D D M M Y Y Y Y

Broker/Relationship Officer)
Received from Mr./Ms. the proposal for Life Insurance with Kotak Mahindra Life Insurance Company
Limited along with ` by way of Cheque**/DD**/Others no.
Dated D D M M Y Y Y Y Drawn Bank, Branch

Date: D D M M Y Y Y Y Place:

NAME SIGNATURE
(Name and Signature of the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker / Relationship Officer)
* Please note that, this is not a money receipt and cannot be used for collection of renewal premium or any other purpose. This acknowledgement is merely an acknowledgement for receipt of
fresh proposal. This acknowledgement does not in any way constitute acceptance or commencement of risk.
**All cheques/demand draft should be crossed and drawn in favour of "KOTAK LIFE INSURANCE" or “Kotak Mahindra Life Insurance Company Limited”.
See overleaf for details.
 APPLICATION NO.:

18. DECLARATION BY THE LIFE ADVISOR/CORPORATE AGENT/BROKER/RELATIONSHIP OFFICER (please cancel what is not applicable and fill all details)
I, ________________________________________________________ (Full Name) in my capacity as the Life Advisor / Specified Person of the Corporate Agent/Authorised Employee of the Broker/
Relationship Officer, do declare that I have explained all the contents of this proposal form, including the nature of the questions contained in this proposal form to the proposer. I have also explained that
the statement(s), information and response(s) submitted by him/her in this proposal form to questions contained herein or any details sought herein will form the basis of the contract of insurance between
the Company and the proposer, if this proposal is accepted by the Company for issuance of a policy. Based on my interaction with the proposer and/or the documents and records that I have been supplied
with, I have no information, which suggests that any of the statement(s), information and response(s) supplied by the proposer or the life to be insured is/are incomplete or untrue.

Licence No. (Life Advisor/Corporate Agent/Broker/Relationship Officer)

For POS agent : AADHAR No. _______________________________________________OR PAN___________________________________________________

Agent ID
(Life Advisor/Corporate Agent/Broker/Relationship Officer)

Place (Signature of the Life Advisor/Specified person of Corporate Agent

/Authorised Employee of Broker/ Relationship Officer)
Date D D M M Y Y Y Y Telephone No.

FOR OFFICE USE ONLY CHECKED BY

NAME OF SALES MANAGER NAME OF SALES ASSOCIATE PROMOTION CODE NAME OF BOE

SALES MANAGER ID SALES ASSOCIATE ID PARTNER CODE BRANCH NAME

D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y

SIGNATURE OF SALES MANAGER SIGNATURE OF SALES ASSOCIATE SIGNATURE SIGNATURE OF BOE

Kotak Mahindra Life Insurance Company Ltd.

Regn. No.: 107, CIN: U66030MH2000PLC128503, Regd. Office: 8th Floor,
Plot # C- 12, G- Block, BKC, Bandra (E), Mumbai - 400 051.
https://www.kotaklife.com

FOR YOUR REFERENCE

1. This is an acknowledgement by the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker / Relationship Officer of having received the
Proposal Form. This is not a receipt issued by Kotak Mahindra Life Insurance Company Ltd.
2. Kotak Mahindra Life Insurance Company Limited shall issue a proposal deposit receipt (PDR) on receiving the completed proposal form with the cash / cheque
/ demand draft at its branch office.
3. In case of non-receipt of your PDR or for any clarification, kindly contact nearest Branch of Kotak Life Insurance.
4. For further assistance, WhatsApp at 9321003007

WhatsApp: 9321003007
https://www.kotaklife.com

Kotak Mahindra Life Insurance Company Ltd.

Regn. No.: 107, CIN: U66030MH2000PLC128503, Regd. Office: 8th Floor,
Plot # C- 12, G- Block, BKC, Bandra (E), Mumbai - 400 051.
https://www.kotaklife.com