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Basics About You

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Single#SNG,Married#MRD,Divorced#DVR,Widow(er)#WDW
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<=6 months#Less,>6 months#More
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Indian#I,NRI#O
Australia #Australia ,Austria#Austria,Belgium#Belgium,Bulgaria#Bulgaria,Canada#Canada,Czech Republic #Czech Republic ,Denmark#Denmark,England#England,Finland#Finland,France#France,Germany#Germany,Greece#Greece,Greenland#Greenland,Holland#Holland ,Hong Kong#Hong Kong,Hungary#Hungary,Iceland#Iceland,Ireland#Ireland,Italy#Italy,Japan#Japan,KOREA (REPUBLIC OF KOREA)#KOREA (REPUBLIC OF KOREA),Kuwait#Kuwait,Luxembourg#Luxembourg,Mauritius#Mauritius,Netherlands#Netherlands,New Zealand#New Zealand,Northern Ireland#Northern Ireland,Norway#Norway,Oman#Oman,Poland #Poland ,Portugal #Portugal ,Romania#Romania,Sardinia#Sardinia,Scotland#Scotland,Sicily#Sicily,Singapore#Singapore,Slovak Republic#Slovak Republic,Slovenia#Slovenia,Spain#Spain,Sweden#Sweden,Switzerland#Switzerland,United Arab Emirates #United Arab Emirates ,United Kingdom #United Kingdom ,United States of America#United States of America,Vatican City#Vatican City,Wales#Wales

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Graduate#GRA,Post Graduate#POG,Professional#PRO,Higher Secondary#HIS,Primary School#PRS,Illiterate#ILL

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It seems you are not eligible to avail Term Plan Insurance. Please check out other products from Max Life and choose the one that suits your need.

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Apologies! Since, you are a Non-resident Indian (NRI), we won't be able to provide you the Waiver of Premium Plus Rider. You can still continue your Term Plan purchase for a reduced premium of

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Employment and Insurance

Employment

Salaried#Salaried,Professional#Profsnl,Self Employed/Business owner#Selfempl,Self Employed from Home#Slfemply,Housewife#Housew,Retired#Retired,Student#Studen,Agriculturist#Agriculture,Labourer#Labourer,Others#Others
CRPF#CRP,Defence#DFN,Oil and Natural Gas#ONG,Merchant Marine#MEM,Mining#MIN,Others#OTH
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E.g. Office job, Mechanical job, Sales job, etc.

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E.g aviation, diving, parachuting, disposal, special services group etc.

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Please enter correct PAN number

Only applicable for NRI or person belongs to Arunachal Pradesh, Manipur, Mizoram, Nagaland, Tripura, Jammu & Kashmir.

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Do you wish to hold this policy electronically with any Insurance Repository? What is Electronic Insurance Policy?

Central Insurance Repository Limited#CIR,Karvy Insurance Repository Limited#KVY,CAMS Repository Services Limited#CAM
Aadhar No
Central Insurance Repository Limited#CIR,Karvy Insurance Repository Limited#KVY,CAMS Repository Services Limited#CAM

Are you or your nominee a politically exposed person (PEP)? What is PEP?

Which of the following person is PEP?

Social Worker#1,MLA#2,MP#3,Others#4
Please specify other roles

Whether the party is in power?

Whether the concerned PEP has ever been posted in a foreign office/Portfolio?

Provide Details

Has the concerned PEP ever been convicted or is under any investigation for any crime punishable by three or more years of imprisonment?

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Insurance History

These details are crucial to process your application. Please state any life insurance cover including savings, investment  or term insurance except for credit life insurance. We may have additional requirements based on the overall insurance coverage.

Do you have any insurance policy for Life/Health/Disability/Critical Illness which has been issued, is pending or that has lapsed?

Max Life Insurance Co. Ltd# Max Life Insurance Co. Ltd , Bajaj Allianz Life Insurance Company Limited .# Bajaj Allianz Life Insurance Company Limited .,Birla Sun Life Insurance Co. Ltd# Birla Sun Life Insurance Co. Ltd ,HDFC Standard Life Insurance Co. Ltd#HDFC Standard Life Insurance Co. Ltd ,ICICI Prudential Life Insurance Co. Ltd#ICICI Prudential Life Insurance Co. Ltd ,ING Vysya Life Insurance Company Ltd.#ING Vysya Life Insurance Company Ltd.,Life Insurance Corporation of India#Life Insurance Corporation of India ,PNB Metlife India Insurance Co. Ltd.# PNB Metlife India Insurance Co. Ltd.,Kotak Mahindra Old Mutual Life Insurance Limited#Kotak Mahindra Old Mutual Life Insurance Limited ,SBI Life Insurance Co. Ltd#SBI Life Insurance Co. Ltd ,Tata AIA Life Insurance Company Limited#Tata AIA Life Insurance Company Limited ,Reliance Life Insurance Company Limited.# Reliance Life Insurance Company Limited.,Aviva Life Insurance Company India Limited# Aviva Life Insurance Company India Limited,Sahara India Life Insurance Co. Ltd.#Sahara India Life Insurance Co~ Ltd.,Shriram Life Insurance Co. Ltd.#Shriram Life Insurance Co~ Ltd.,Bharti AXA Life Insurance Company Ltd.# Bharti AXA Life Insurance Company Ltd.,Future Generali India Life Insurance Company Limited#Future Generali India Life Insurance Company Limited,IDBI Federal Life Insurance Company Ltd.# IDBI Federal Life Insurance Company Ltd,Canara HSBC Oriental Bank of Commerce Life Insurance Company Ltd.# Canara HSBC Oriental Bank of Commerce Life Insurance Company Ltd.,AEGON Religare Life Insurance Company Limited.# AEGON Religare Life Insurance Company Limited. ,DLF Pramerica Life Insurance Co. Ltd.#DLF Pramerica Life Insurance Co. Ltd.,Star Union Dai-ichi Life Insurance Co. Ltd.#Star Union Dai-ichi Life Insurance Co. Ltd.,IndiaFirst Life Insurance Company Limited# IndiaFirst Life Insurance Company Limited,Edelweiss Tokio Life Insurance Co. Ltd.#Edelweiss Tokio Life Insurance Co. Ltd.,Others#Others
Policy No
Total Sum Assured
Issued#Issued,Pending#Pending,Lapsed#Lapsed
Life#Life,Health#Health,CI(Critical Illness)#DD,Disablity#Accident
Name Sum Type Status

Has your application for life/health/critical illness insurance or its reinstatement ever been offered at modified terms, rejected or postponed?

Max Life Insurance Co. Ltd # Max Life Insurance Co. Ltd ,Bajaj Allianz Life Insurance Company Limited .# Bajaj Allianz Life Insurance Company Limited .,Birla Sun Life Insurance Co. Ltd # Birla Sun Life Insurance Co. Ltd ,HDFC Standard Life Insurance Co. Ltd #HDFC Standard Life Insurance Co. Ltd ,ICICI Prudential Life Insurance Co. Ltd #ICICI Prudential Life Insurance Co. Ltd ,ING Vysya Life Insurance Company Ltd.#ING Vysya Life Insurance Company Ltd.,Life Insurance Corporation of India #Life Insurance Corporation of India ,PNB Metlife India Insurance Co. Ltd.# PNB Metlife India Insurance Co. Ltd.,Kotak Mahindra Old Mutual Life Insurance Limited #Kotak Mahindra Old Mutual Life Insurance Limited ,SBI Life Insurance Co. Ltd #SBI Life Insurance Co. Ltd ,Tata AIA Life Insurance Company Limited #Tata AIA Life Insurance Company Limited ,Reliance Life Insurance Company Limited.# Reliance Life Insurance Company Limited.,Aviva Life Insurance Company India Limited# Aviva Life Insurance Company India Limited,Sahara India Life Insurance Co~ Ltd.#Sahara India Life Insurance Co~ Ltd.,Shriram Life Insurance Co~ Ltd.#Shriram Life Insurance Co~ Ltd.,Bharti AXA Life Insurance Company Ltd.# Bharti AXA Life Insurance Company Ltd.,Future Generali India Life Insurance Company Limited#Future Generali India Life Insurance Company Limited,IDBI Federal Life Insurance Company Ltd# IDBI Federal Life Insurance Company Ltd,Canara HSBC Oriental Bank of Commerce Life Insurance Company Ltd.# Canara HSBC Oriental Bank of Commerce Life Insurance Company Ltd.,AEGON Religare Life Insurance Company Limited. # AEGON Religare Life Insurance Company Limited. ,DLF Pramerica Life Insurance Co. Ltd.#DLF Pramerica Life Insurance Co. Ltd.,Star Union Dai-ichi Life Insurance Co. Ltd.#Star Union Dai-ichi Life Insurance Co. Ltd.,IndiaFirst Life Insurance Company Limited# IndiaFirst Life Insurance Company Limited,Edelweiss Tokio Life Insurance Co. Ltd.#Edelweiss Tokio Life Insurance Co. Ltd.,Others#Others
Policy No
Name of Insurance Company
Total Sum Assured
Declined for Medical Reasons#Declined for Medical Reasons,Extra Premium#Extra Premium,Coverage Reduction#Coverage Reduction,Postponed#Postponed
Life#Life,Health#Health,CI(Critical Illness)#DD,Disablity#Accident
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Lifestyle & Well-being

Travel and Adventure

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Are you involved in any hazardous activities/ occupation/ Sports/ Hobby?

Please select your activity

In the next 1 year, do you intend to travel or reside abroad for more than four weeks?

USA#USA,UK#UK,UAE#UAE,Dubai#DUB,Australia#AUS,South Africa#SA,Singapore #SGP,Malaysia#MYS,Japan#JPN,France#FRA,Other#OH
Meeting Family/Friends#Meeting,Business#Business,Hospitalization#Hospital,Studies#Studies,Contract#Contract,Consultancy#Consult,Conference#Conference,Others#Others
Please enter duration of stay more than 4 weeks

Habit

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Do you consume or have ever consumed Tobacco/Nicotine products in the last one year?

Cigarette#Cigarette,Beedis#Beedis,Cigar#Cigar,Gutka#Gutka,Flavoured Pan Masala#FlavouredPanMasala,Khaini#Khaini
Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally
Type Frequency qunatity noOfYears

Do you consume or have ever consumed alcohol?

Beer#Beer,Wine#Wine,Hard Liquor#HardLiquor
Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally
Type Frequency qunatity noOfYears

Do you consume or have ever consumed illegal drugs; such as cannabis/ marijuana/ ecstasy/ heroin/ LSD/ amphetamines or other illegal drugs?

Cannabis#Cannabis,Marijuana#Marijuana,Ecstacy#Ecstacy,Heroin#Heroin,LSD#LSD,Amphetamines#Amphetamines,Other illegal drugs #Other illegal drugs
Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally
Type Frequency qunatity noOfYears

Height & Weight

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Feet-Inches#FT,Cms#CM

Health

Your premium may increase basis the medical conditions disclosed by you and subject to underwriting assessment.

Have you ever been investigated, diagnosed or treated for any of the following? Check all that apply.

Cardio

Hormonal

Respiratory

Blood/Cellular

Digestive/Regulatory

Mental/Psychiatric ailment

Neural/Skeletal/Muscular

Infectious/Contagious

Have you ever been hospitalized or been advised to undergo any investigation (other than routine check-up) or treatment or any surgery?

Family History

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Has any of your family members (Parents & Siblings)  ever been diagnosed with Diabetes, Hypertension,Kidney Failure,Cancer,Heart Attack or any Hereditary Disorder before the age of 60?

Mother#Mother,Father#Father,Brother#Brother,Sister#Sister,Spouse#Spouse
Good Health#Good Health,Diabetes#Diabetes,Heart Attack#Heart Attack,Heart Disease#Heart Disease,Hypertension#Hypertension,Kidney Disorder#Kidney Disorder,Multiple Sclerosis#Multiple Sclerosis,Adenomatous Polyposis#Adenomatous Polyposis,Hemophilia#Hemophilia,Neurological Disorder#Neurological Disorder,Parkinson's Disease#Parkinson Disease,Policystic Kidney Disease#Policystic Kidney Disease,Sickle Cell Anemia#Sickle Cell Anemia,Alzeimer's Disease#Alzeimer Disease,Cancer#Cancer,Huntington's Disease#Huntington Disease,Muscular Dystrophy#Muscular Dystrophy,Motor Neuron Disorder#Motor Neuron Disorder,Dystrophia Myotonica#Dystrophia Myotonica
Member age disease

In the last 1 year, have you been absent from work or an educational institute due to illness or injury for a continuous period of more than 10 days?

Criminal Charges

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Have you ever been convicted or are you under investigation for any criminal charges?

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Apologies! We won't be able to provide you with the Waiver of Premium Plus Rider, basis your health details. You can still continue your Term Plan purchase for a reduced premium of

In case you selected 'Diabetes' by mistake, click 'Reselect' to try again.

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Payor Details

Is the premium payment done by someone else other than you (Payor)?

Mother#Mother,Father#Father,Brother#Brother,Sister#Sister

Please note that 'Know Your Customer (KYC) documents, i.e., ID proof, address proof and latest photograph of the person making the payment would be required as per regulatory guidelines. So, kindly email us at online@maxlifeinsurance.com or upload them.

Male#M,Female#F

Confirm Your Details

Name

Father's/Husband's Name

Date of Birth

Gender

Marital Status

Full name prior to marraige

Spouse's Occupation

Total Insurance cover on Spouse

Spouce's Annual Income

Is Pregnant

Number of months

Mobile Number

Email Address

Nationality

Country of Birth

Passport Number

Passport Issuing Country

Current Country of Residence

Full Address in the Country of Residence Overseas

Telephone Number not pertaining to India

Date of Latest Entry to India

Country/Countries visited frequently

PAN Number

Type Of Visa

Visa valid till

Education

Communication Address

Permanent Address

Occupation Type

Industry Type

Name of the Employer

Job Title

Annual Income

Nature of Duties

Place of Posting

Rank

Armed forces branch

Are you involved in hazardous activity?

Business Name

PAN (Permanent Account Number)
Form 60

Neither my income nor the income of any other person in the respect of which i am assessable under the act in the excess of the maximum amount not chargeable to income tax in any previous year

Do you wish to hold this policy electronically with any Insurance Repository? What is Electronic Insurance Policy?

Provide existing E-Insurance Account Number

Preferred Insurance repository that you would like to have IA with

Please enter your 12 digit Aadhar card number

Are you or your nominee a Politically Exposed Person (PEP)?

Which of the following persons in PEP

Life Insured
Family member(s) of life insured

Extent of Political Envolvement

Political experience(in years)

Affiliations to Political Party

Role in Political Party

Role in Political Party Others

Portfolio handled

Whether the party is in power

Whether the concerned PEP has ever been posted in a foreign office/portfolio?

Please provide details

Please specify all sources of income of concerned PEP

Has the concerned PEP ever been convicted or is under any ivestigation for any crime punishable by three or more years of imprisonment?

Please provide details

Insurance History

Do you have any insurance policy for Life/Health/Disability/Critical Illness which has been issued, is pending or that has lapsed?

Has your application for life/health/critical illness insurance or its reinstatement ever been offered at modified terms, rejected or postponed?

Title

First Name

Middle Name

Last Name

Father's/Husband's Name

DOB of Nominee

Gender

Relation with Nominee

Relation

Appointee Name

Relation with Appointee

Bank A/C Number

Account Holder Name

IFSC Code

MICR code

Bank and Branch Name

Type of Bank Account

Banking Since

Travel and Adventure

Are you involved in any hazardous activities/ occupation/ Sports/ Hobby?

In the next 1 year, do you intend to travel or reside abroad for more than four weeks?

Country

City

purpose

Duration of stay in weeks

Height and Weight

Height In

Weight (in kgs)

If your weight has changed by more than 5kgs,in the past 1year, please give reasons

Habit

Do you consume or have ever consumed Tobacco/Nicotine products in the last one year?

Do you consume or have ever consumed alcohol?

Do you consume or have ever consumed illegal drugs; such as cannabis/ marijuana/ ecstasy/ heroin/ LSD/ amphetamines or other illegal drugs?

Health

Cardio

High blood pressure

When was high blood pressure diagnosed?

Please provide the details of the medication

How often do you attend for follow ups and when was your last consulation

What was your last blood pressure reading?

Details:

Hormonal

High blood Sugar/Diabetes

When was Diabetes/high blood sugar diagnosed?

Are you on Insulin/Tablets or both? please give details of medication and dosage

Do you follow a stirct diet

Have you ever had numbness or tingling in your feet/ legs? If yes, provide details.

How often do you attend for follow ups and when was your last consulation?

What was your last blood sugar reading?

Details:

Respiratory

When was this condition diagnosed?

Please describe your symptoms and do your symptoms make you wake up at night?

How often do the symptoms occur in the last 12 months?

Please provide medication details( currently and in past).

Have you ever taken steroids? If Yes, then please provide details.

Details:

tuberculosis from 2 months

When was this condition diagnosed?

Please describe your symptoms and do your symptoms make you wake up at night?

How often do the symptoms occur in the last 12 months?

Please provide medication details( currently and in past).

Have you ever taken steroids? If Yes, then please provide details.

Blood/Cellular

Details:

Blood test

Digestive/Regulatory

Details:

Mental/Psychiatric ailment

Mental/Psychiatric ailment
Disease of nervous system

Details:

Mental test

Neural/Skeletal/Muscular

Details:

Neural test

Infectious/Contagious

Details:

Infectious test
Any other medical condition

Details:

No,I have never been Investigated/diagnosed or treated for any of the mentioned diseases.

Details:

No diseases

Have you ever been hospitalized or been advised to undergo any investigation (other than routine check-up) or treatment or any surgery?

Provide Details

In the last 1 year, have you been absent from work or an educational institute due to illness or injury for a continuous period of more than 10 days?

Provide Details

Family History

Has any of your family members (Parents & Siblings) ever been diagnosed with Diabetes, Hypertension,Kidney Failure,Cancer,Heart Attack or any Hereditary Disorder before the age of 60?

Criminal charges

Have you ever been convicted or are you under investigation for any criminal charges?

Details of charges and conviction outcome

Is the premium payment done by someone else other than you (Payor)?

Name of Payor

Gender

PAN Number

Relationship with Life Insured

Address

Annual Income

Date of Birth

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