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4. PREFERRED LANGUAGE FOR COMMUNICATION

1. ARE YOU AN EXISTING SBI LIFE CUSTOMER? If Yes, provide Customer ID/ Policy No.:

Do you want to assign this policy on issuance? Yes NoIf Yes, please submit relevant documents/annexure with the Proposal Form

2. ASSIGNMENT:

Registered & Corporate Office: Natraj, M. V. Road, & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. IRDA Registration No. 111

Yes No

Application No.

3. e-INSURANCE A/C DETAILSe-Insurance A/c No: Repository Name:

Identity Proof : PAN Card Voters I.D. Card

Gender Male Female

Age Proof :

Driving Licence Aadhar Card Others (Pls. Specify)

Others (Pls. Specify)PAN Card School/College Cert

Date of Birth : (DDMMYYYY)

5. DETAILS OF PROPOSERMr. Ms. Mrs.

:

Middle Name :

Last Name :

Maiden Name (for female proposers only)

Father's Name :

First Name

:

Nationality : Indian NRI(NRIs are not eligible for coverageunder this product)

Qualifications : Others (Pls. Specify)SSC Under GraduateHSSC Illiterate

STAMP

STAMP

STAMP

STAMP

STAMP

STAMP

STAMP

STAMP

FOR OFFICE USE ONLY

Occupation ::

Marital Status :: DivorcedMarriedSingle

Business Service Housewife Agriculturalist Others (Pls. Specify)

Widow/Widower

Please submit self attested copy of PAN Card or PAN Exemption Form in case the total premium paid in a year under all policies held by you exceeds ` 50,000 or above.In case the total premium paid in a year under all policies held by you exceeds ` 1 lakh and above please submit documents to show the fund source

Annual Income : ` PAN *:

Instructions for filling up Proposal Form(1). This form is to be filled by the Proposer in BLOCK LETTERS in BLACK INK. In case the Proposer is unable to fill in the form, the person filling in the form must complete the declaration in vernacular section of this form. (2). Please tick a box where appropriate & all Questions should be answered. (3). The proposer must authenticate any cancellation or alterations in this form. (4). Insurance is a contract of utmost good faith, which requires Insurer, Proposer/ Life to be Assured to disclose all material facts. In case of any doubt as to whether a fact is material or not, the fact should be disclosed. (5). All documents submitted with this proposal form must be self attested by the Proposer. (6). Please attach an extra sheet, where ever additional information is to be given.

Others (Pls. Specify)I. T. Return/ Assessment Order/ Employers CertIncome Proof :

CHANNEL DETAILS (This section to be filled by Sales Representative):

Agency Corporate Agency (SBG)Broking

(Pls Specify)Others

Direct

Is this Proposal sourced through Distance Marketing? Yes No. If Yes, please state the Distance Marketing Mode :

Corporate Agency (CS) Corporate Agency (Alternate Channel)

Sourcing Branch Code:

For Alternate Channel / Corporate Agency (SBG) Only:

Bank/ Broker/ CA Code:

IA/CIF/SP Code: I A/CIF Name:

Bank/ Broker/ CA Name:

Sourcing Branch Name:

Worksite Code:

Code 3Code 2Code 1

Copy of PANDocument Submitted Form 60/61

SBI LIFE INSURANCE COMPANY LTD.

SBI Life - Smart Guaranteed Savings PlanSimplified Underwriting Product

Proposal Form

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Page 2 of 4# Important: Incase you have not, please provide your email id and mobile number to help us serve you better.Incase you do not have a mobile, please provide your landline telephone number.

Application No.

Communication Address: C/o, W/o, D/o, S/o, Other (if any): ______________________________________

House No. & Bldg/ Society Name:

Pin:

Road/ Sector & Landmark:

#Mobile No .: Tel. No. (Office):

#Email ID :

State:

Country: #Tel. No. (Home) :

S T D P H O ON NE

S T D P H O ON NE

Village / City:

District:Taluka / Tehsil:

7. PREMIUM PAYMENT TERM (PPT) 7 YRS. THE POLICY TERM WILL BE 15 YEARS

^Please note that SBI Life branches and its sales team are not authorised to collect cash from its customers

If the premium is remitted through Draft/Cheque then the same should be issued in favour of ‘SBI Life Insurance Co. Ltd.-Proposal Form No.____________’

Bank / Branch Name

9. DETAILS OF PREMIUM REMITTANCE :Is deposit for premium under this proposal paid by you (if answer is no, please provide required information under point 15 of the proposal form)Yes No

Draft/ Cheque No Branch Code Date of EFT/ Cheque Customer A/c Number Amount (`)

Name

Date of Birth

Relationship with Life Assured

Gender$Address

Percentage of Entitlement

Nominee Appointee*

Relationship with Nominee

(Signature of the Appointee)

Sign Here

Details Mr. Ms. Mrs.

6. DETAILS OF NOMINEE AND APPOINTEE:

N.A

N.A

*Where Nominee is a minor, details of an Appointee to be provided$Address of Nominee to be provided if different from the Proposer In case of more than one nominee - please attach an extra sheet & percentage of entitlement should total to 100%

10.DO YOU HAVE ANY OTHER INDIVIDUAL LIFE INSURANCE POLICY OR HAVE YOU APPLIED FOR ONE?Yes No If Yes, please provide details below

Additional sheets with relevant details may be added if space is insufficient

Name of Insurance Co.

Policy / Proposal No. Yearly Premium (`)

Sum Assured ( )`

Self/Spouse/Parent (Pls. specify)

Policy Status

Including SBI Life - Smart Guaranteed Savings Plan. Kindly note cumulative premium under this product can not exceed 75000`

Mr. Ms. Mrs.

Others (Pls. Specify)

Address Proof: Telephone Bill Ration Card Bank A/C Statement

Letter from Recognized Public Authority

Electricity Bill

Sum Assured Basic Premium Payabale (A) Service Tax Amount (B) Total Installment Premium (A+B)

` ` ` `

1. Have you ever been denied life insurance cover or granted cover with an extra premium or lien or with a restrictive clause, by any insurer?2. Have you suffered, treated , hospitalized or currently suffering from diabetes or elevated blood sugar, Cancer/Leukemia/Lymphoma , disease of heart or brain,

stroke, paralysis, epilepsy, any mental or neurological or genetic disorder, respiratory disease(Asthma, Pneumonia, COPD etc), or chronic disease of the lungs, kidney, liver, or HIV or digestive disorder (Ulcer, Gastric bleeding etc) or chronic infections, circulatory/blood disorder, thalassemia major, bleeding disorders, rheumatoid arthritis, SLE or any other auto immune or connective tissue disorders etc or Hepatitis B or C infection or abuse of alcohol or narcotic drugs.

3. Do you have any physical deformity or congenital/acquired (disease, accident, neurological deficit etc) defect or impairment of hearing or vision (except use of hearing aid or reading glass) or irregular gait or speech or involuntary movements of limbs or require assistance in carrying out your routine activities (support of wheel chair, clutches etc)

4. During the last 5 years, have you been hospitalized for any ailment or diseases for a period of 7 days or more in continuity or underwent tests or procedures like biopsy, angiography, dialysis, MRI, CT scan?

5. For Female Lives onlyi) Are you presently pregnant?ii) Have you suffered from illness related to breast, uterus, or ovary?6. Are you exposed to any special hazard associated with your occupation (e.g. mines, chemical factory, explosives, corrosives.) which may render you susceptible to

injuries or illnesses? If Yes, please give details, ___________________________________________________________If the answer to any of the questions. (1-6) is YES, please note your proposal shall not be eligible for coverage.

7. Are you a “Politically Exposed Person” (PEP) or a close relative of PEP?PEPs are individuals who are or have been entrusted with prominent public functions, i.e. heads / ministers of central / state govt., senior politicians, senior govt, judicial or military officials, senior executives of govt. companies, important political party officials, immediate family member of above persons (would include spouse, parents, siblings, children, spouses parents or siblings and close associates of PEPs.)

8. Do you have any history of conviction under any criminal proceedings in India or abroad? If yes, please give details _____________________________________________________

11. MEDICAL AND OTHER DETAILS OF THE LIFE TO BE ASSURED:TickY N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

8. BACKDATING : (Available for SBI Life - Smart Guaranteed Savings Plan ) (DDMMYYYY)

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I. I wish to Backdate the Policy : Yes No ii. Backdating Date : (Policy will be backdated to a date within the same Financial Year in which the policy has been taken)

SI EFT MANDATE (To be filled by Policyholder and all fields are mandatory) Declaration OverleafI hereby submit my Bank account details for payment of renewal premium through Standing Instruction (SI Facility) under my policy.

1. Policy No: 2. Proposal No:

3. Name of Policy Holder: ____________________________________ 4. Premium Amount: _____________________________________

5. Mode of the Policy: Annual

6. Start Date: 7. End Date:

8. Particulars of the Bank account

a. Name of Account Holder: ______________________________ b. Account Number:

c. Branch Code: d. Bank and Branch Name: _________________________________

9. Proof of bank account submitted: Original cancelled cheque with preprinted name Self attested photocopy of passbook/ account statement.

I agree/confirm that I have read the declaration given overleaf. (Mandatory)

Signature of Account Holder Signature of Policy Holder (If Account Holder & Policyholder are different)

Application No.

(DDMMYYYY)(DDMMYYYY)

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 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. (2) 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 of the Insurance Act, 1938: “ 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 in question 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 statements was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose;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.”

13. DECLARATION BY THE PROPOSERI do hereby agree and declare that these statements and this declaration shall be the basis of the contract of assurance between me and SBI Life Insurance Co. Ltd. (Company) and that if there is any mis-statement or suppression of material information or if any untrue statements be contained therein the said contract shall be absolutely null and void and all monies which shall have been paid in respect thereof shall be forfeited to the Company and surrender value, if any, will be payable subject to Section 45 of the Insurance Act, 1938.

I also understand and agree that the company shall additionally levy or recover all the applicable taxes like Service Tax, Surcharges, Cess, etc. from the premium which are necessitated by various enactments of Central and/or State Legislatures from time to time.

I authorize the Company to share information pertaining to my proposal including the medical records with any Governmental and/or Regulatory authority. Further, the information may be shared for the sole purpose of proposal underwriting and claims settlement.

Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital and/or employer from divulging any knowledge or information about me concerning my health, employment on the grounds of secrecy, I, my heirs, executors, administrators and assignees or any other person or persons having interest of any kind whatsoever in the policy contract issued to me, hereby agree that such authority, having such knowledge or information, shall at any time be at liberty to divulge any such knowledge or information to the Company.

I further agree that if after the date of submission of this proposal but before the acceptance of risk or issue of the policy document by the Company (i) if there are any adverse circumstances connected with the general health of myself, or (ii) if a proposal for assurance on my life made to any other insurance company has been withdrawn or dropped or accepted at an increased premium or on terms other than as proposed by me, or, (iii) if there is any change in my occupation, I shall forthwith intimate the same to SBI Life Insurance Co. Ltd. in writing to reconsider the terms of acceptance of this proposal. Any omission on my part to do so shall render the contract of assurance invalid. I understand and agree that SBI Life will not be responsible for any delay in premium payment irrespective of any mode for remittance opted.

I understand that the contract will be governed by the provisions of the Indian Insurance Act 1938, and other applicable Statutes and prevailing laws in India and that the risk cover will not commence until a written acceptance of this proposal is issued by the Company and that the risk cover and other benefits under the policy shall be subject to the terms and conditions contained in the contract of assurance. I also agree that the amount held in proposal/policy deposit shall not earn any interest.

I further state that the product features and the terms and conditions of the policy have been thoroughly explained to me and that I consent to the same.

“I further request SBI LIFE to send me any information relating to this proposal or the resulting policy through SMS/ Email /Phone/ Letter and hereby give my consent to receive such information through SMS/ Email/ Phone/ Letter, notwithstanding any Regulations/ Statutory provisions to the contrary. This consent shall hold good even if I register my number with the National Customer Preference Register (NCPR).”

“I hereby declare that the deposit for this proposal has been paid from my own source/ income”***

"I hereby understand and agree that no physical policy document will be issued to me if I have requested for issuing this insurance policy in electronic format to my eInsurance Account. I also agree to receive all policy related communication through electronic means, i.e., email, SMS, calls, etc."

*** (Strike off in case � DECLARATION TO BE GIVEN IF THE PERSON/ORGANISATION PAYING THE PREMIUM IS DIFFERENT FROM THE PROPOSER� is applicable) - Please Note SBI Life - Smart Guaranteed Savings Plan is a Limited Premium Policy and I am aware that I would need to pay premium for____ years (Premium Payment Term)

Signature/Left Thumb impression of the Proposer

(Please sign in black Ink only)Signature/ Left Hand Thumb Impression

Signature of Witness :

Place:

Date: (DDMMYYYY)

Affix a recentself signedphotograph

I declare that the information given above is true and correct. I shall not hold SBI Life responsible for non–credit/non-payment of payout or refund, if any, due to any reason including but not limited to incorrect/incomplete information. I hereby authorise SBI Life to directly credit payout/refund, if any, to the above mentioned account. #Valid Resident Indian Account *Please submit cancelled cheque with pre-printed account holder name along with Proposal Form.

12. BANK ACCOUNT DETAILS OF PROPOSER/LIFE TO BE ASSURED (MANDATORY):

SI EFT MANDATE (To be filled by Policyholder and all fields are mandatory) Declaration OverleafI hereby submit my Bank account details for payment of renewal premium through Standing Instruction (SI Facility) under my policy.

1. Policy No: 2. Proposal No:

3. Name of Policy Holder: ____________________________________ 4. Premium Amount: _____________________________________

5. Mode of the Policy: Annual

6. Start Date: 7. End Date:

8. Particulars of the Bank account

a. Name of Account Holder: ______________________________ b. Account Number:

c. Branch Code: d. Bank and Branch Name: _________________________________

9. Proof of bank account submitted: Original cancelled cheque with preprinted name Self attested photocopy of passbook/ account statement.

I agree/confirm that I have read the declaration given overleaf.

(Mandatory)

Signature of Account Holder Signature of Policy Holder (If Account Holder & Policyholder are different)

(DDMMYYYY)(DDMMYYYY)

Place:

Date:

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“I further request SBI LIFE to send me any information relating to this proposal or the resulting policy through SMS/ Email /Phone/ Letter and hereby give my consent to receive suchinformation through SMS/ Email/ Phone/ Letter, notwithstanding any Regulations/ Statutory provisions to the contrary. This consent shall hold good even if I register my number with theNational Customer Preference Register (NCPR).”

DECLARATION:

I hereby declare that the particulars given overleaf are correct and complete. I am aware of the Standing Instruction payment option. I agree to discharge my responsibility expected of me as a participant under the option .I also give my consent to deduct the premium as per the variations in the premium amount in future due to change in Service Tax and other applicable levies as per Government directives.

I also understand that the premium amount will be debited from my account mentioned overleaf on the Due Dates and in case the amount cannot be debited from my mentioned account for any reasons whatsoever and if as a result of failure of payment of renewal premiums through this mechanism, the policy lapses, this SI facility will not be operative till the policy has been brought to ‘inforce’ status by me and I undertake to pay the premiums due, directly to SBI Life.

I further understand and agree that this facility has been offered to me as a service gesture and I agree that SBI/Associate Bank or SBI Life may withdraw this facility at their sole discretion, at any time, without assigning any reason whatsoever.

I undertake that it shall be my sole responsibility to keep the policy inforce by making timely remittances of due premiums notwithstanding this SI EFT mandate.

I further declare and undertake that I shall not hold Bank as well as SBI Life liable if the policy is lapsed due to failure of the server / electronic system or for any reasons beyond the control of SBI in transmitting the premium via Electronic Fund Transfer.

Application No.

I hereby declare that I have read out and explained the contents of this proposal form and all other documents incidental to availing the insurance policy from SBI Life Insurance Company Ltd. to the Proposer and that he/she said that he/she has understood the same and that he/she agrees to abide by all the terms and conditions of the same.I hereby declare that I have fully explained to the Proposer the answers to the questions that form the basis of the contract of insurance and that if any untrue statement is contained herein, the company shall have the right to vary the benefits that may be payable, and further, if there has been non-disclosure of a material fact that the said contract shall be absolutely null and void and all monies which shall have been paid in respect thereof shall be forfeited to the Company and surrender value, if any, will be payable subject to Section 45 of the Insurance Act, 1938. I hereby declare that I have explained the contents of this form to the Proposer in___________________ Language, that I have truly and correctly recorded the answers given by the Proposer and that the Proposer has affixed his/her thumb impression on the proposal form in my presence, after fully understanding the contents thereof.

14. DECLARATION WHEN THE PROPOSAL FORM IS FILLED BY A PERSON OTHER THAN THE PROPOSER/PROPOSER SIGNS IN A VERNACULAR LANGUAGE/ PROPOSER IS ILLITERATE:

Signature of the Person making the Declaration:__________________________

Name and Address: _____________________________________________________________________________

Place: Date: (DDMMYYYY)

Bank Name (For CIF Only)

Bank Code (For CIF Only)

Branch Name Address (For CIF Only) Address Tel. No./ Fax No.

Name of the Life to be Assured

Branch Code (For CIF Only)

Proposal No.

CONFIDENTIAL REPORT OF SALES REPRESENTATIVE(To be Completed by the Sales Representative after receiving the completed Proposal Form)

Name of the Sales Representative Sales Representative Code No.

Moral Hazard Questions:

1. Have you personally met the proposer / Life to be assured and verified his identity

2. a) What is the general state of health of the Life to be assured?

b) Does he /she have any physical deformity or mental retardation?

c) Has he /She undergone hospitalization or any surgery as per your information. If yes give full particulars.

3. Are you aware of any apparent risk factors with regard to his /her health and habits or any others issue that are likely to add to the risk? If yes give details.

4. Whether the Proposer/Life to be assured is a Politically Exposed Person (PEP) or family member /close relative of any PEP?

Y N

“I do hereby confirm that the above proposal is canvassed by me & I certify that I have taken all possible precautions to ensure compliance with the KYC/Anti Money Laundering guidelines and the Anti Money Laundering policy of the company and verified at best of my knowledge that the prospect is not an anonymous fictitious/ or a benami person. I recommend this case for acceptance”.

Signature of Sales Representative

(Please sign in black ink only)

Date: D D M M Y Y Y Y (DDMMYYYY)

Moral Hazard Report(To be completed, based on the independent assessment, for Proposals with Sum Assured 5 lacs and above.)? I have discussed the Proposal with the Sales Representative.? I have scrutinized the Proposal Form, the Sales Representative Report and on the basis of my

independent enquiries, I recommend the Proposal for acceptance. Signature of the UM/BDM/Supervisory Sales Representative

(Please sign in black ink only)

Name of the UM/BDM/Supervisory Sales Representative:

Date: DD MMYYYY(DDMMYYYY)

Y N

Y N

Y N

Y N

15.

Signature/Left thumb impression of the proposer __________________________.

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Signature of Witness __________________________.