Note:

1. The premium shown above is indicative for Tier 1 Bank, Group Class 5000 and above and calculated assuming that the Insured Member is a normal healthy person.
2. Sub-standard lives will be covered with appropriate extra premium as per the Company's underwriting guidelines.
3. Goods and Services Tax will be charged on premiums as per prevailing tax laws. Currently the applicable Goods and Services Tax is 18% of the Single Premium. This is subject to any change in the tax rate.
4. For more details on risk factor, terms and conditions, please read the Sales brochure of the plan carefully before concluding a sale.

In case you require any clarification, please consult your insurance advisor or call our office.

I .............................................. (Name), having received the information with respect to the above, have understood the above statement before entering into the contract.

Signature of the Specified Person / Agent / Other Sales Representative :

Company Seal:                                                         Policyholder's signature

Name of the Specified Person / Agent / Other Sales Representative :
Specified Person / Agent / Other Sales Representative Code :
Place:
Date: