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Ver 8

App Received Date: 2011-09-26

Form ID-01

CAFOS Code

IMPORTANT GUIDELINES:

LOB / Agent Code

Channel Code

Advisor/FSC Name

FSM/FSC Code:

LIM/CSR Code:

Bank A/C:

Bank Branch Source

OL00133810

00066918

DM NA

NA

NBNK 00DM 0WEB

Application number:

Proposer should use only his/her credit card OR internet banking account for payment of premium. Use of credit card OR internet

The policy will be issued on the basis of the Date of Birth provided on the application form.

Insurance is a contract of utmost good faith requiring of the Proposer / Life Assured not only to disclose all material facts but also not

Please enter Representative's identification code:1. Full name: This is how your name will appear on the policy certificate. Please leave a space between each part of the name.

Were you assisted by an authorized representative? :

Please fill the details as provided by the authorized representative, for tracking this application

A. PERSONAL DETAILS

First Name Surname

Rajesh Sharma

Father / Husbands Name: Ramesh Sharma

2. Date of Birth:

4. Gender: 5. Marital Status:

6. Nationality:

3. Age Proof:

13. Communication Address:

Line1:

Line2:

Landline:

Land Mark: City:

State:

Country:

4/09/1974

Male Married

Indian

LIC Policy - standard proof

Flat No 366, Vijay Vilas,

Off Ghodbunder Road,

25970301

Behind Muchhala College Thane

Maharashtra

India

(The policy would be issued basis the disclosure made regarding Date of Birth. Company reserves the right to call for the age proof any time after

the policy issuance )

9. Organization:8. Occupation:

7. Education:

10. Designation:

Graduate

11. Your Annual Income:

Salaried Public Ltd

1050000Project Manager

12. Are you a Politically Exposed Person (PEP):

Mobile:

Pin Code: 400607

9920245811

14. Permanent address (if different than above)

Line1:

Line2:

Landline:

Land Mark: City:

State:

Country:Mobile:

Pin Code:

Email ID:

15. Do you have any existing life cover and/or are you simultaneously applying for life cover with ICICI Prudential

If Yes please provide the following detailsNo

Total Amount 0

16. Do you have any existing life insurance cover with other companies?

If Yes please provide the following detailsYes

* Terms of acceptance (decision) Standard, Revised premium, Postponed, declined, offered with modified terms.

* Terms of acceptance (decision) Standard, Revised premium, Postponed, declined, offered with modified terms.

00066918

No

No

This online process is applicable only to Resident Indians and the payment would be accepted in INR only

The Life Assured, Proposer and payer shall be the same person and cannot be different.

Policy number Basic Sum Assured Base Plan / Rider Decision*

to suppress any material facts in response to the questions in the proposal form. Kindly note that any non-disclosure of information or

misstatement in the form may lead to decline of proposal/repudiation of claim arising out of this policy by the company.

banking account of persons other than the Proposers will lead to decline of proposal/payment.

Life Insurance Co. Ltd.

750000 StandardLIC India

Name Of Company Basic Sum Assured Base Plan / Rider Decision*

Opportunity ID:

E Business Company..

rajsh.sharma@gmail.comEmail ID:

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5. Address (to be filled if different from Life Assured's communication Address)

Line1:

Line2:

Landline:

Land Mark:

State:

Country:

Flat No 366, Vijay Vilas,

Off Ghodbunder Road,

25970301

Behind Muchhala College

Maharashtra

IndiaMobile: 9920245811

City: Thane Pin Code: 400607

C. APPOINTEE DETAILS (Only if the nominee is a minor)

2.Date of Birth: 3.Gender:

1.First Name Surname

4.Relationship to Life Assured:

D. HEALTH DECLARATION

Note: Please enter correct details on the medical questionnaire below to enable smoother processing of claims.

c) Have you had any loss or gain of weight of 10 Kg or more in the last 6 months?

b) Weight

1. a) Height

No

84 kg

5'8''

2. Do you consume or have you ever consumed Tobacco or any nicotine products in any form.

If Yes please provide the following detailsNo

Substance

consumed

Response If yesConsumed as If YesDuration(No

of years)

If YesFrequency /

day

NMNMNO

Please provide the following details if you consume or have ever consumed the following:

Substance

consumed

Response If yesConsumed as If YesDuration(No

of years)

If YesFrequency /

Week

NMNO NM

NO

Alcohol

Narcotics

Tobacco

3. Life style details of the life to be assured.

Is your occupation associated with any specific hazard or do you take part in hazardous activities or have hobbies thatcould be dangerous in any way or do you intend to travel, live or work outside India for more than six months?

5. Health details of the life to be assured.

No

4. Family details of the life to be assured.Before age 50, have any of your natural parents or siblings died or suffered from cancer, heart disease, stroke, highblood pressure, diabetes, kidney diseases, polycystic kidney or any hereditary disease ?

No

a. Are you currently under medical treatment or being advised to take medical treatment and /or suffering from any

investigations such as X-ray, scanning (ultrasound, CT,MRI,PET), biopsy, Pap smear, mammogram,angiogram,electrocardiogram (ECG), blood or urine test or been hospitalized for observation, treatment or surgery?

surgery,organ transplant, excision of tumour or growth or been admitted to hospital for two days or more or receivedcontinuous medical treatment for five days or more (for reasons other than flu, common cold, throat infection, sprains,fever)?

No

No

No

d. Have you ever suffered or been diagnosed with or been treated for any of the following:

i)Epilepsy, stroke, transient ischemic attack, double vision, paralysis, weakness of limb, persistent headache, nervous

ii)Diabetes, high blood sugar, thyroid or other glands disorders or any other endocrine disorders?

heart murmur, heart valve disease or disorders, breathlessness, palpitations, chest discomfort or pain, disease of orany other disorder of the heart, blood or blood vessels?

iv)Asthma, persistent cough, coughing with blood, pneumonia, tuberculosis, breathing discomfort or anyother lung or No

No

No

No

No

B. NOMINEE DETAILS

2. Date of Birth: 3. Gender:15/9/1979 Female

1. First Name Surname

Shikha Sharma

4. Relationship to Life Assured: Spouse

physical or mental impairment or congenital abnormality?

b. In the recent ten years, have you undergone or been advised to consult a specialist doctor or undergo any tests or

c. Have you ever undergone any surgical procedure(s) including - angioplasty, bypass surgery, brain surgery, heart

breakdown, depression or any other nervous/mental disorders?

iii)Anaemia, haemophilia, raised cholesterol, high blood pressure or other cardiovascular conditions- e.g.heart attack,

respiratory system disorders?

disorders?

v)Chronic Gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach,intestines or bowel

rajsh.sharma@gmail.comEmail ID:

NM

NM

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Section 41: In accordance to the Section 41 of the Insurance Act, 1938, 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.

Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own

life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub section if at the time of such acceptance

the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the insurer.

Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred

rupees

Section 45 - Policy not to be called in question on ground of mis-statement after two years.No policy of life insurance effected before the

commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance

effected after the coming into force of this Act shall after the expiry of two years from the date on which it was effected, be called inquestion by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or

friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that

such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the

policy-holder and that the policy-holder knew at the time of making it that the statement was false or that it suppressed facts which it was

material to disclose.

I confirm that all premiums will be paid from bonafide sources.

I further declare that the premium is being paid from my credit card/internet bank account.

The Claimant shall be required to produce the valid age proof of the policyholder, as acceptable to the Company in the event of claim.

The Company reserves the right to accept, decline or offer alternate terms on my proposal for life insurance.

In order to enable the Company to assess the risk under this proposal and any time thereafter, I hereby, authorize the past and present

employers(s)/ business associates/ medical practitioner/ hospital / any life and non-life insurance Company/or organization or Life

Insurance Associations medical register to release to the Company and the Company to release to any life and non-life insurance

Company/or Life Insurance Association or medical register, such details and provide the records of employment/business or other

details as may be considered relevant.

This proposal form shall be a part of the life insurance policy contract, in case of its acceptance by the Company

Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy

shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life

insured was incorrectly stated in the proposal.

I declare that I am submitting a proposal for life insurance to ICICI Prudential Life Insurance Company Ltd. (Company) through the

Companys website, after satisfying myself of the truthfulness of the statements made by me herein and of the need to disclose all material

facts, as required under Section 45 of the Insurance Act, 1938.

I understand and I agree that by submitting this proposal through the Company website, I will be bound by such statements / non-disclosure

of material facts in the same manner and to the same extent as if I have signed and submitted a written proposal for insurance to the

Company.

, having received the information with respect to the above, have understood theI

statement before entering into the contract

Rajesh

8. Tax Benefits would be available as per the prevailing Income Tax laws.

6. There are no maturity benefits under the plan

7. ICICI Pru iProtect Option II is only the name of the policy and does not in any way indicate the quality of the policy.

9. Service tax and education cess would be levied as per applicable tax laws.

10. For any further clarifications, please feel free to contact us or e-mail us on lifeline@iciciprulife.com

11. Insurance is the subject matter of solicitation.

Important Terms and Conditions:

I declare that I have answered the questions in the proposal form of ICICI Prudential Life Insurance Company Limited, (hereinafter

referred to as the Company) and have fully understood the nature of the questions including health related questions and the

importance of disclosing all material information while answering such questions. I further declare that the answers given by me to allthe questions in the proposal form of the Company as to the state of health and habits of the life to be assured, that is mine, are true

and complete in every respect and that I also understand that any mis-statement or suppression of material information or where the

Company is not notified of the change in health the Company has the right to repudiate the claim under this policy. I undertake to notify

the Company of any change in the state of health of the life to be assured, that is mine, or as to my occupation subsequent to the

signing of this proposal and before the acceptance of the risk by the Company. I also understand that in case of any mis-statement or

suppression of material information the Company has the right to decline the application/repudiate the claim under this policy in

accordance with Section 45 of the Insurance Act. I also understand that the terms and conditions including the premium and the benefits

payable under the policy are subject to taxes/duties/charges in accordance to the applicable laws.