Customer Declaration For Submission Of Online Application

Download Customer Declaration For Submission Of Online Application

Preview text

Customer Declaration For Submission Of Online Application

To, Reliance Nippon Life Insurance Co. Ltd

Application No_______________________ Product Name_______________________ Product UIN_________________________

I/We_______________________________________(Name) request you to process the Application for_____________________solicited through Tablet. (Product Name)_______________________. I/We confirm that I/ we have read relevant documentation/ information and have understood the product and Riders (if any), features, benefits and its associated risk. I/ We agree that post my/our meeting with Mr/Ms_______________________(Name) bearing code_________I/we has/have submitted the application to buy this product of my/our own accord. Benefit illustration has been explained to me and have understood the same before entering into the contract I/We understand and agree that by submitting this application through the Tablet, I/ We will be bound by such statements / disclosures of material facts in the same manner and to the same extent, as if I/ We have signed and submitted a written proposal for insurance to the Company.

I/ We undertake to notify Reliance Nippon Life Insurance Company Limited ("the Company") of any change in the information with respect to the life to be assured subsequent to the submitting of this application and before the acceptance of the risk by the Company. I/We fully understand the nature of the questions including health related questions and the importance of disclosing all material information to the Company while answering such questions in this application. By clicking on the box available on Tab, I confirm that I have read and agree to the Terms and condition of RNLIC.

I/We declare that answers given by me/us to all the questions captured through Tablet application including the information given to the Company as to the state of health & habits of the life/lives to be assured are true and complete in every respect.

I/We understand that in case of fraud or any mis-statement or suppression or non disclosure of material information submitted or where the Company is not notified of any change as mentioned above, the Company reserves the right to repudiate the claim or declare the policy void in accordance with Section 45 of the Insurance Act as amended from time to time.

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

I hereby declare and confirm that the contact number________________________________and Aadhar number__________________________given in the proposal form belongs to me.

I hereby declare and confirm that I am making the premium payment towards this application through my own bank account/credit card and I agree to submit a third party declaration in case the premium payment is not made from my own account. I declare that the premiums paid have not been generated from the proceeds of any criminal activities /offences and I shall abide by and confirm to the prevention of Money Laundering Act, 2002 or any other applicable laws.

I / We Understand that with effect from October 1, 2015 Reliance Nippon Life Insurance Company Limited has advised all customers / policyholders to insist on a receipt at the premium collection point, upon collection of the premium amount by the Reliance Nippon Life Insurance officials and for this purposes, we / I need to necessarily come to branch of Reliance Nippon Life Insurance Company Limited to deposit the premium either in cash or by cheque. Therefore, we / I understand that premium either in cash or cheque if handed over to an agent / advisor or any other persons is at our / my risk and responsibility.

(Name of Life Assured / Proposer) (Signature of Life Assured / Proposer)

Mobile No_________________ Date____________________ Place_________________

DECLARATION FOR SIGNING IN VERNACULAR OR FOR UNEDUCATED PERSON I hereby declare that the content of this form has been explained to the Policyholder and have truthfully recorded the answers provided to me.

Signature of Declaration in English Name___________________



Original Document verification by Sales Person I hereby declare that the copies of customer KYC documents submitted with proposal forms has been verified by me with originals and found that all the details and signature are matching with the respective KYC documents. I hereby confirm that I will transfer, the premium amount collected, to RNLIC immediately in compliance with Section 64VB of the Insurance Act, 1938.

Sales Person Name:________________________Sales Person Sign____________________________Sales Person code no:_____________________

Reliance Nippon Life Insurance Company Limited (formerly known as Reliance Life Insurance Company Limited). IRDAI Registration No: 121. Registered Office: H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400710. For more information or any grievance, 1. Call us between 9am to 6pm, Monday to Saturday on our Toll Free Number 1800 102 1010 or 2. Visit us at or 3. Email us at: [email protected] Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited & Nippon Life Insurance Company and used by Reliance Nippon Life Insurance Company Limited under license.

Beware of spurious phone calls and fictitious/fraudulent offers IRDAI clarifies to public that 1. IRDAI or its officials do not involve in activities like sale of any kind of insurance or financial products nor invest premiums. 2. IRDAI does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone call, number.

Page 1 of 1

CIN: U66010MH2001PLC167089 Mktg/Manual Form CDF/V1/June2018

Preparing to load PDF file. please wait...

0 of 0
Customer Declaration For Submission Of Online Application