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Please read the sales brochure carefully for details on risk factors, terms and conditions of the product before filling this proposal form. Insurance is the subject matter of the solicitation.

Insurance is a contract of utmost good faith and the Life to be Insured/Proposer (If different from Life to be Insured) is required to disclose all material facts to the insurer. All answers to the questions stipulated in this Proposal form are the basis of and are an inseparable part of the policy of insurance. In case of doubt as to whether a fact is material or not, the fact should be disclosed. In the event,Life to be Insured/Proposer (If different from Life to be Insured) is unable to fill the form due to inability to read or understand the language, the help of another person may be used. (Refer to Section 10 - Declaration in case the proposal form is filled by a person other than the proposer or signed in vernacular). Please answer all questions. If any of the questions are not applicable please write N.A and please tick a [box] ✓ where appropriate/applicable. Any correction/alteration in this form needs to be signed by the Life to be Insured/Proposer (If different from Life to be Insured). Should you choose to pay premium by cash you are advised to do deposit the same at the nearest branch office of the Company.You are advised not to hand over cash to the sales person. The Company shall not be held responsible for any risk/loss arising out of the customer handing over any money to the sales person.Please read the sales brochure carefully for details on risk factors, terms and conditions of the product before filling this proposal form. Insurance is the subject matter of the solicitation.

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Insurance is the subject matter of the solicitation.
 

*For a non-smoking healthy 30-year old male for a 20 year term and death benefit option 1. Actual premium would depend on age, premium payment term and on underwriting decision. GST and education cess will be charged extra as per the prevailing rates. Premium can be paid only in annual or semi-annual mode. #Minimum age while applying should be 30 years for cover up to age 75. Services of Dedicated Claims Handler (‘DCH’) is limited to only helping the claimants in filling up the forms, arranging to collect the documents from the claimant, and providing information about the status of claim on an ongoing basis on request. While the DCH will facilitate the submission of the claims document for processing the claim, the claim itself will be paid only if admissible under the terms and conditions of the Policy and is subject to receipt of required documents by the Company. The services of DCH cannot be treated as right of the claimant. Availing or otherwise of this service will not have any impact on the decision of the claim by the Company. Flexible Payout Option can only be chosen at inception of the policy

Insurance is the subject matter of the solicitation. Life Insurance Coverage available.

Bharti AXA Life Insurance Company Limited (IRDA Regd. No. 130), Regd. Address: Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra.Service Unit address- Bharti AXA Life Insurance Company Limited, Spectrum tower, 3rd Floor, Malad link road, Malad (west), Mumbai 400064. Maharashtra. Bharti AXA Life eProtect UIN: 130N052V03, Bharti AXA Life eAajeevan Sampatti+ UIN 130N072V03, Bharti AXA Life eProtect+ UIN: 130N072V03, Bharti AXA Life eFuture Invest UIN: 130N072V03, Bharti AXA Life Invest Once UIN: 130N072V03. Advt. No: II-July-2015-1124