Duplicate

29-Jul-2012

MR. TAPAS PAIK

VIJAY RANJAN PAIK BESIDE
HILL VIEW C OPP KAVERI HOTEL
.,JAMSHEDPUR
EAST SINGHBHUM 831018
JHARKHAND
G.O. Name : X1775
Policy No. : 868974403
Telephone : 9771183316
Email ID : Please inform us for regular updates
Subject - Welcome to Max Life Insurance Family
Dear MR. TAPAS PAIK,
Thank you for choosing Max Life Insurance as your preferred life insurance partner.
I welcome you to the rapidly expanding and satisfied family of Max Life Insurance policyholders. We are committed to
offering you world-class Life and health insurance solutions backed by the highest standards of customer service.
Over the last eleven years in our journey to build India's most admired life insurance company, we have created a
strong, profitable and successful institution. In the financial year 2011-2012, the Company became the largest non-bank
promoted private life insurer in India.
■ Profitable growth: Total revenue - Rs. 6,391 crore; Enterprise profit - Rs. 733 crore
■ Financially strong and stable: Solvency margin - 534%, against IRDA mandated 150%; Solvency surplus of
Rs.1,703 crore; Paid up capital - Rs.2,127 crore
■ National presence: In over 1,000 cities across India
■ Large customer base: Over 60 lakh policies sold since inception
■ Quality customer service: Low customer complaint incidence; Outstanding claims ratio - 1.6% only
We are delighted to inform you that the Company enters its next phase of growth with a new partner, Mitsui Sumitomo
Insurance Co. Ltd. alongwith our majority partner, Max India. Mitsui Sumitomo has bought 26% stake of New York Life
Enterprise in our company. With this development, we are now known as Max Life Insurance Co. Ltd. Kindly note
that your premiums are to be paid in the name of Max Life Insurance Co. Ltd.
The enclosed policy explains all the features, benefits and terms of your Max Life Insurance policy, in a simple and
easy to comprehend manner. In the unlikely event of your not being completely satisfied with the policy, you have the
option to cancel it by returning the original policy with a written request to us within 15 (fifteen) days from the date of
receipt. In such a case, the premium paid will be refunded to you in accordance with the terms of the policy contract.
We will be delighted to offer any assistance or clarification you may require about your life insurance policy. We look
forward to being your partner for life.

Yours Sincerely,

Rajesh Sud
Managing Director & CEO

AGENT NAME: AXIS BANK LTD MANGO (445045), PH.NO.:

ADDRESS:Sankusai, Dimna Road, Mango, Jamshedpur 831012 (N/A)

NB13
Max Life Insurance Co. Ltd
11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Phone 2561700 Fax 2389268 (From Delhi and Other cities: 0124) Customer Helpline: 1800-200-4006
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxlifeinsurance.com E-mail: [email protected]

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 Policy Document
Max Life Life Gain Plus 20 Participating Plan
UIN-104N014V01

Max Life Insurance Company Limited

Regd.Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi - 110 020

Max Life Insurance Company Limited (the ``Company'') has entered into this contract of insurance
(the ``Policy'') on the basis of the Proposal together with the premium deposit and declarations
received from the Proposer for effecting a life insurance contract on the life of the person (the ``Life
Insured'') named in the schedule hereto (the ``Schedule''). This Policy is subject to the terms and
conditions stated herein and the Schedule.

The Company agrees to pay the Benefits under this Policy on the happening of the Insured Event,
while this Policy is in force.

Signed by and on behalf of

Max Life Insurance Company Limited

AnaljitSingh
Chairman

Date Of Policy : 29-Jul-2012

NB56
Max Life Insurance Co. Ltd
11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Phone 2561700 Fax 2389268 (From Delhi and Other cities: 0124) Customer Helpline: 1800-200-4006
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxlifeinsurance.com E-mail: [email protected]

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 THE SCHEDULE PAGE
BASE POLICY - Max Life Life Gain Plus 20 TYPE OF POLICY - Participating
Participating Plan GENERAL OFFICE - AXIS BANK LTD Mango

POLICY NO : 868974403 PROPOSAL NO : 868974403

CLIENT ID : 5000731794 DATE OF PROPOSAL : 18-Jul-2012

POLICY HOLDER / PROPOSER : SEX : Male

MR. TAPAS PAIK
ADDRESS : PAN NO. : ALYPP4330M
VIJAY RANJAN PAIK BESIDE
HILL VIEW C OPP KAVERI HOTEL .,JAMSHEDPUR
EAST SINGHBHUM 831018
JHARKHAND

LIFE INSURED SEX : Male

MR. TAPAS PAIK
DATE OF BIRTH OF LIFE INSURED
19-Jan-1972
ADDRESS :
VIJAY RANJAN PAIK BESIDE
HILL VIEW C OPP KAVERI HOTEL .,JAMSHEDPUR
EAST SINGHBHUM 831018
JHARKHAND

NOMINEE (S) APPOINTEE (In case Nominee is a minor)

MS.KAKALI PAIK

EFFECTIVE DATE OF COVERAGE : 18-Jul-2012

PREMIUM MODE : Annual

PREMIUM METHOD : Two-stage autopay BILLED DRAW DATE : 23RD

AGENT'S DETAILS
NAME : AXIS BANK LTD MANGO CODE : 445045
ADDRESS : MOBILE/ LANDLINE NUMBER :
Sankusai, Dimna Road, Mango
Jamshedpur 831012 (N/A)

LIST DURATION INSURED SUM MODAL DUE DATES ANNEXURE MODAL

OF OF EVENT INSURED PREMIUM WHEN REFERENCE FLAT EXTRA
COVERAGES COVERAGE (`) (`) PREMIUM PREMIUM
PAYABLE;
DATE
WHEN LAST
INSTALLMENT
OF PREMIUM
DUE
BASE POLICY
Max Life Life 20 Years Maturity or 735939 96466.88 18th of Jul NA
Gain Plus 20 Death of Every Year;
Participating Plan Life Insured 18-JUL-2017

RIDER(S)
Max Life Term 6 Years Death of 100000 491 18th of Jul TRM NA
Rider (Par)- Limited Life Insured Every Year;
pay 06 yrs 18-Jul-2017
TOTAL SERVICE TAX FOR ALL COVERAGES UNDER BASE POLICY AND RIDER(S) : `1551.1
TOTAL MODAL PREMIUM FOR ALL COVERAGES UNDER BASE POLICY AND RIDER(S) : `98508.98
THE BENEFITS ARE PAYABLE TO :
The Policy Holder or his assignees or nominees or proving executors or administrators or other legal representatives
who shall take out representation to his estate from a competent court.
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Note: "The Policy shall stand cancelled in the event of non realization of the first premium deposit by the company"
SPECIAL PROVISIONS :
Premiums are payable for a period of 6 years from the effective date of coverage. Therafter no further premium is
required to be paid by you for the remaining duration of coverage referred to in the schedule.

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 BENEFITS
DEFINITIONS 1) Maturity
In this Policy, you; your; refers to the life insured if he is also the PolicyHolder or Upon maturity of the policy we shall pay you Sum Insured as specified in
the PolicyHolder if he is not the life insured, we; us; our; ours; ''the Company'' the Schedule together with sum assured of PUA, if any, and a guaranteed
refers to Max Life Insurance Company Limited. additional bonus of 10 (ten) percent of the Sum Insured.
''Age'' means the age of the Life Insured attained on the last birthday on or 2) Death Benefits
prior to the Effective Date of Coverage specified in the Schedule. I) Subject to the Policy remaining in full force, on the death of the Life Insured,
''Effective Date of Coverage'' means the date shown in the schedule page we shall pay the following Benefits under this policy :
on which the coverage of risk under your Policy has commenced. i) On death of Life Insured, we shall pay 100% of the sum assured plus
''Policy Holder'' means the person who owns the Policy. sum assured of paid up additions, if the policy is in force for less than
''Life Insured'' means the person on whose life the policy is being effected. 5 years.
''Diagnosis'' shall mean the definitive diagnosis made by a Registered
Medical Practitioner, based upon radiological, clinical, histological or laboratory ii) On of Life Insured, we shall pay twice the sum assured plus sum
evidence acceptable to the Company. All diagnosis are subject to acceptance assured of paid up additions, if any, if the policy has been inforce for
and concurrence by the Company's appointed doctor. In the event of any doubt 5 years or more
regarding the appropriateness or correctness of the diagnosis, the Company iii) On death of Life Insured before 10(ten) years of age we shall refund
shall have the right to call for examination of the Life Insured and / or the the premiums with compound interest at the rate of 4(four) percent per
evidence used in arriving at such diagnosis, by an independent expert selected annum subject to maximum of sum assured.
by the Company. The opinion of such expert as to such diagnosis shall be II) On Death of the Policy Holder (if the Policy Holder and the Life Insured are
binding on both the PolicyHolder and the Company. different persons)
''Registered Medical Practitioner'' shall mean any medical practitioner Subject to the Policy remaining in full force, on the death of the PolicyHolder,
qualified by degree in medicine and registered with the Medical Council in India, the Life Insured shall have the option to continue the policy by payment of
who possesses sufficient skill and competence to render medical or surgical premiums.
services in respect of the disease concerned, but excludes a Registered
3) Terminal Illness benefits
Medical Practitioner who is the Policy Holder or the Life Insured or the spouse
or lineal relative of the Policy Holder/ Life Insured. While this Policy is in force, should the Life Insured be diagnosed to be suffering
''Indebtedness'' shall mean any amount due/outstanding payable to the from a disease which, in the opinion of a Registered Medical Practitioner
Company including any premium, revival charges, loan and interest thereon. and the concurrence of the Company's appointed doctor, is likely to lead
''Miscellaneous'' All terms and references to masculine shall also apply to to the death of the Life Insured within six months from the date of such
feminine and reference to singular shall also include the plural and vice and diagnosis (''Terminal Illness''), the Company shall at the Policy Holder's
versa. request, pay the Benefits to the Life Insured under this Policy as follows :
a) Upto 50% of the Sum Insured, subject to a maximum cumulative of ` 5 lakhs
PREMIUM PROVISIONS (Rupees Five Lakhs only) under all policies which provide for this Terminal
Illness Benefit, then in force with the Company, on the approval of Terminal
Payment of Premium Illness claim filed; and
Premiums are payable to us on the due dates specified in the Schedule. Upon the payment of Terminal Illness Benefit(s), the benefits under all policies
The Premium Mode can be changed subsequently, upon our receipt of your then in force with the Company with respect to the Life Insured, which
written request. However such change shall become effective on the Policy provide for this Terminal Illness Benefit, will be proportionately reduced and
anniversary date. Change sought to Premium Mode will lead to a revision in will be payable in accordance with the terms of the respective policies. If any
the Modal Premium amount. claim has already been made under the Dread Disease Rider (if any), the
PolicyHolder shall not be entitled to the Terminal Illness Benefits under this
Grace Period Policy. Additionally, all Riders, pertaining to Life Insured under this Policy, will
We allow a grace period of thirty days from the due date for payment of end upon such payment
each Premium. In case premium mode is monthly, the grace period shall be
During the period of survival of the Life Insured all premiums due shall be paid
fifteen days only. During the grace period we will accept the premium without
to keep this policy in force.
interest. The insurance coverage continues during this grace period but if
b) The remainder of the Sum Insured, upon the occurrence of the Insured
the Life Insured dies during the grace period, the Company shall be entitled to
Event.
deduct the unpaid Premium from the Benefits payable under the Policy.
Terminal Illness Benefit is not available where the Life Insured is under 18
Non-payment of Premium (eighteen) years of age.
If a Premium is not received by us by the end of the Grace Period, the 4) Non-Forfeiture Benefits
Policy will lapse. If the Policy has cash value then it will be subject to Non If the Policy has Surrender Value, you may surrender your policy for cash or
Forfeiture/Automatic Premium Loan Provision, elected by you in the Proposal exercise any one of the following non-forfeiture options, as opted for by you in
Form or as per your subsequent request, in writing, from the due date of such the Proposal Form or subsequent election in writing.
unpaid Premium. All Insurance cover will end at the time of lapse if the Policy
(i) Reduced Paid up Insurance
has no cash value. We must receive such notice, in writing, no later than one
month from the date of expiry of the grace period. A reduced paid up insurance is the amount of paid up insurance, which can be
purchased by the Surrender Value.
Revival of Policy This reduced paid up insurance may acquire cash value, which entitles you to
Within three years after the Policy has lapsed you may apply for revival of the take loan/s. If at any time the outstanding indebtedness exceeds the surrender
Policy, if you have not surrendered it. We may upon written request from you, value of the paid up policy, the paid up policy will lapse. Such paid up policy
and on production of evidence of insurability acceptable to us (cost of which is not entitled to any bonus.
to be borne by you), and at our discretion revive the Policy on such terms and (ii) Extended Term Insurance (ETI)
conditions as are applicable at the time of revival. All overdue Premiums must The Surrender Value will be used as a single Premium to buy Term Insurance
be paid together with interest at such rates as may be declared by us from time equal to the current Sum Insured of this Policy for a term, which the Surrender
to time. The revival of the Policy shall take effect only after it is approved, in Value can purchase. The maximum term for this ETI cannot exceed the
writing, by us. remaining term of this Policy. Should the Surrender Value be sufficient to buy
a single premium Term Insurance for a term longer than the remaining term of
At the time of revival any unpaid loan and any loan deducted when we this Policy, then such excess amount will be returned to the PolicyHolder. Such
determined the non-foreiture benefit, must also be repaid. Interest on the loan ETI is not eligible for bonus or cash value.
will be compounded once every year and will be based on loan interest rate The minimum term for ETI is five year. If the surrender value is not sufficient to
that were in effect at the time of lapse. purchase ETI for five years or more the surrender value will be paid in cash.
All or part of the payment can be availed as a new unpaid loan if there BONUS
is sufficient cash value available after the revival of the Policy to cover the
loan. We do not need evidence of insurability if we receive the required While this policy is in force it is entitled to bonus, if any, declared by the
payment within 30 days after the expiry of the grace period, but the insured company. No bonus is payable for the first two Policy years. Bonus, if any, is
must be living when we receive it. payable on the Policy anniversary, from the surplus arising from the actuarial
If the Policy has been surrendered and the benefits under the Policy, if any, valuation of the participating life insurance fund, if all premiums due before
has been paid by us, this Policy can not be revived. then have been paid. Notwithstanding anything to the contrary, Bonuses are
The cost of providing evidence of insurability would be actual medical always non-guaranteed.
examination fee plus an administrative fee for revival of policy, which would be The bonus will be applied as per the options selected by the policyholder in
not more than ` 1000/-. The administrative fee may vary depending upon the the Proposal :
annual inflation rates. 1. Cash Bonuses : The Bonuses declared will be paid to the policyholder
in cash.

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2. Premium Offset - This entitles the policyholder to offset the premium Surrender Value
payable by him/her under the Policy against the bonuses, if any. In After the Policy has acquired Cash Value, you may opt to surrender this
the event the bonus is in excess of the premium payable under the Policy. The Surrender Value payable will be subject to the condition that the
policy, the excess will be paid to the policyholder in cash. However, if Policy is in full force and that there are no statutory or other restrictions to the
the bonus is not sufficient, the shortfall should be paid in full before this contrary. The Surrender Value payable will be equal to Cash Value less any
option can be exercised. loan including interest accrued to date of surrender.
3. Paid Up additions - This entitles the policyholder to utilize the bonus, Loan(s)
if any, to buy single premium endowment benefits, which will mature After the Policy has acquired a Cash Value it will be eligible for loan/s. The
along with the base policy. In the event of death of the Life Insured maximum amount of loan/s at any point in time shall not exceed ninety percent
prior to maturity, the company shall pay Sum Insured of single premium of the Cash Value or such other percentage as the Company may determine
endowment benefits, if any. from time to time. You will be liable to pay interest on such loans as may
While the Policy is in force, the policyholder may make a written request to be determined by the Company on a quarterly basis up to a maximum of five
change the bonus option. per cent points over and above the bank rate prevailing at the time when the
loan application is sanctioned by us and also comply with all other terms and
At any time while the Policy is in force and the paid up additions have acquired conditions as stipulated by us. Interest on loan will be compounded once
Cash Value, the policyholder may surrender such paid up additions, partially every year.
or in full, subject to minimum surrender value of ` 5000/- and not more than Any loan/s granted will form a first charge against the Policy proceeds and will
once in a policy year. be deducted before any payment is made on the Policy.
GENERAL PROVISIONS At any point in time, should the loan and accumulated interest exceed the Cash
The Contract Value, the Policy will lapse. The minimum amount of loan that can be granted
The entire contract consists of this policy including schedule, attached at any time will be Rupees ten thousand only.
riders and endorsements if any, the proposal, medical evidence, any written Automatic Premium Loan (''APL'')
statements, answers, premium deposits and other declarations/particulars (if In case you have elected APL option in the Proposal and the Policy has
any) received from you. The contract may be amended by us with your Surrender Value, which must be sufficient to take a loan for paying the overdue
consent. No Agent is authorized to change the contract. premium, we will provide you with an automatic loan to pay the overdue
Full Disclosure & Incontestability premium at the end of the grace period. In case premiums have been paid
This Policy has been issued on your representation that you have made through APL for two years in a row, the next premium cannot be paid through
full disclosures of all relevant facts and circumstances. Any concealment, APL. However, if at any time Surrender Value is not sufficient to take a loan
non-disclosure, misrepresentation or fraud by you shall render the Policy liable for paying full overdue premium, you will be liable to pay the full premium,
for cancellation and/or voidable at the option of the Company. If it deems fit, failing which the Policy will lapse and the Surrender Value, if any, will be paid
the Company may also forfeit the Premium(s) received. to you. All other conditions regarding APL will be those as specified under
We also draw your attention to Section 45 of the Insurance Act, 1938 - which ''Loans''.
states as follows : You can also cancel this election for future premiums, by giving a notice in
No policy of life insurance effected after the expiry of two years from the date writing to us.
on which it was effected be called in question by an insurer on the ground that Nomination and Assignment
a statement made in the proposal for insurance or in any report of a medical The person named by you in the proposal form as the nominee/s, shall be the
officer, or referee, or friend of the insured, or in any other document leading person to whom the benefit under the Policy will be paid in the event of death of
to the issue of the policy, was inaccurate or false, unless the insurer shows the Life Insured. Such nomination only indicates the person, who is authorized
that such statement was on a material matter or suppressed facts which it was to receive the amount on the payment of which we will receive a valid discharge
material to disclose and that it was fraudulently made by the policy-holder and of our liability under the Policy. Change in nomination, if any, may be made
that the policy-holder knew at the time of making it that the statement was by you any time during the term of the Policy and must be registered with us.
false or that it suppressed facts which it was material to disclose. Provided that You may also assign the benefits under the Policy in favour of the person
nothing in this section shall prevent the insurer from calling for proof of age at named by you whereby the beneficial interest, right and title under the
any time if he is entitled to do so, and no policy shall be deemed to be called in Policy gets transferred to such person. You can assign the entire Policy
question merely because the terms of the policy are adjusted on subsequent with Riders, if any, and not individual covers. An absolute assignment shall
proof that the age of the life insured was incorrectly stated in the proposal. automatically cancel a nomination except any assignment in favour of the
Policy Review Period Company. Notice of assignment (including any change thereof) should be
Please examine your Policy carefully. You may opt to return the Original Policy submitted for registration to the Company.
to the Company with a written request for cancellation of the Policy within fifteen In registering an assignment or nomination, the Company does not accept any
days from the date of receipt of this Policy. In such an event the Premiums paid responsibility or express any opinion as to its validity or legality.
less proportionate risk premium for the period of cover, any medical fees and Suicide Exclusion
expense incurred on stamp charges by the Company will be refunded without Notwithstanding anything stated in the Policy, if the Life Insured under the
interest. If the Policy is sent by post it shall be deemed to have been received Policy dies by suicide, whether sane or insane, within one year from the Date
by you within three days of posting. of Policy or the Effective Date of any revival of this Policy, the Policy Coverage
Currency and Place of Payment shall come to an end simultaneously. In such an event, we will only refund
All payments to or by us will be in Indian Rupees at any of our offices in India, the Premium(s) received from the Date of Policy or the effective date of any
or any other office as specified by the Company. revival, whichever is later, without interest, less any expenses incurred by us.
Travel, Residence and Occupation Claims
This Policy contains no restrictions as to travel, residence or occupation except Subject to full disclosure and incontestability provision stated above and the
as otherwise provided in any Special Provisions to this Policy or by law. Policy remaining in full force and we have satisfactory proof of the happening
Misstatement of Age or Sex of the insured event in relation to the Life Insured, its cause, Claimant's
All Premiums are calculated based on the Age or Sex of the Life Insured Statement, Original Policy, Death Certificate, Attending Physician's statement,
declared in the Proposal. Without prejudice to the full disclosure and Hospital Treatment Certificate, Burial/Cremation Statement, Employer's
incontestability provisions, the Company may in its sole discretion : Certificate, F.I.R / Postmortem report (wherever applicable), Photo-identity
i) in case the age at the time of issuance of Policy is lower or higher than proof of the Claimant, documents establishing right of the Claimant and such
the age declared or sex is mis-stated, adjust the premium and/or benefits other documents required by the Company at that time, we will settle the claim.
payable to those applicable had the true age or sex been stated at issue and Notices
the policy would have been issued based on our underwriting rules at that time All communications relating to this policy may be addressed to :
and Max Life Insurance Co. Ltd
ii) in case the Life Insured's true age at the time of issuing the Policy is higher 11th floor, DLF Square,
than the maximum issue age limit under the Policy, cancel the Policy and forfeit Jacaranda Marg,
Premium(s) received. DLF City, Phase II,
Vesting on attaining majority Gurgaon - 122 002,
If the Policy has been issued on the life of a minor, the Policy will automatically Haryana.
vest in him on his attaining majority (eighteen years) and thereafter the Life
Insured would be the Policy holder and the Company shall enter into all Dispute Redressal Cell
correspondence directly with him. Any assignment or nomination of the Policy 1. All consumer grievances may be first addressed to the Company's
contrary to this provision would be null and void against the Company. Customer Complaint Resolution Unit at 90A,Sector 18, Gurgaon, 122002,
Cash Value Haryana, India or the servicing General Office as mentioned in the
Non guaranteed cash values as decided by the Appointed Actuary. Schedule or write to us at [email protected].
This Policy will acquire cash value if it has been in force for at least three years 2. In case the Policyholder is not satisfied with the decision of the above office,
and provided all the Premiums that have fallen due have been received. The or has not received any response within 2 weeks, he may contact by way of
guaranteed cash value in this policy will be 30% of the Premium(s) (excluding a written complaint signed by him or by his legal heirs with full details of the
the first year's Premium) received. complaint and his contact information, to the following official for resolution:

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 Head Operation and Delivery
Max Life Insurance Co. Ltd
Plot No. 90A, Sector 18
Gurgaon, 122002, Haryana, India
Toll free - 1800-200-4006
Email - [email protected]
3. In case the Policyholder is not satisfied with the decision/resolution of
the Company or has not received any reply within a period of Thirty (30)
days from the Company, the Policyholder may approach the insurance
ombudsman, at the address mentioned in Appendix A, if the grievance
pertains to:
(i) any partial or total repudiation of claims by the Company;
(ii) Any dispute on the legal construction of the Policy in so far as such
disputes relate to claims;
(iii) Delay in settlement of claim;
(iv) Any dispute with regard to Premium paid or payable in terms of the
Policy; or
(v) Non-issue of any insurance document after receipt of Premium.
You can obtain address of the insurance ombudsman from Our Office or
from the IRDA website address www.irdaindia.org. The List of Ombudsman
is also attached as Appendix A.
4. As per provision 13(3) of the Redressal of Public Grievances Rules 1998,
the complaint to the insurance ombudsman can be made within a period of
one year after the insurer has rejected the representation or sent his final
reply on the representation of the complainant, provided the complaint is
not on the same matter, for which any proceedings before any court, or
consumer forum or arbitrator is pending.

Taxes
All premiums and benefits are subject to applicable taxes and levies including
service tax, which shall be borne by the Policyholder. The Company shall be
entitled to collect such applicable taxes and levies from the policyholder as
per prescribed procedure.

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ENDORSEMENT

Total stamp value : `167.18

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 APPENDIX A: List of Ombudsman
Office of the Name of the Contact Details Areas of CV of the
Ombudsman Ombudsman Jurisdiction Ombudsman
AHMEDABAD Shri P. Insurance Ombudsman, Office of the Insurance Ombudsman, Gujarat, UT of CV of Shri P.
Ramamoorthy 2nd Floor, Ambica House, Nr. C.U. Shah College, Ashram Road, Dadra & Nagar Ramamoorthy
AHMEDABAD-380 014. Tel.: 079-27546840, Fax : 079-27546142, Haveli, Daman and
Email : [email protected] Diu
BHOPAL Insurance Ombudsman, Office of the Insurance Ombudsman, Madhya Pradesh &
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel, Near Chhattisgarh
New Market, BHOPAL(M.P.)-462 023. Tel.: 0755-2569201, Fax :
0755-2769203, Email : [email protected]
BHUBANESHWAR Shri B. P. Parija Insurance Ombudsman, Office of the Insurance Ombudsman, 62, Orissa CV of Shri B. P.
Forest Park, BHUBANESHWAR-751 009. Tel.: 0674-2596455, Fax : Parija
0674-2596429, Email : [email protected]
CHANDIGARH Insurance Ombudsman, Office of the Insurance Ombudsman, Punjab, Haryana,
S.C.O. No.101-103, 2nd Floor, Batra Building. Sector 17-D, Himachal Pradesh,
CHANDIGARH-160 017. Tel.: 0172-2706468, Fax : 0172-2708274, Jammu & Kashmir,
Email : [email protected] UT of Chandigarh
CHENNAI Shri V. Insurance Ombudsman, Office of the Insurance Ombudsman, Tamil Nadu, UT - CV of Shri V.
Ramasaamy Fathima Akhtar Court, 4th Floor, 453 (old 312), Anna Salai, Pondicherry Town Ramasaamy
Teynampet, CHENNAI-600 018. Tel.:- 044-24333668 / 5284, Fax : and Karaikal (which
044-24333664, Email : [email protected] are part of UT of
Pondicherry)
NEW DELHI Shri Surendra Pal Insurance Ombudsman, Office of the Insurance Ombudsman, 2/2 Delhi & Rajasthan CV of Shri
Singh A, Universal Insurance Bldg., Asaf Ali Road, NEW DELHI-110 Surendra Pal
002. Tel.:- 011-23239633, Fax : 011-23230858, Email : Singh
[email protected]
GUWAHATI Shri D. C. Insurance Ombudsman, Office of the Insurance Ombudsman, Assam, Meghalaya, CV of Shri D. C.
Choudhury "Jeevan Nivesh", 5th Floor, Near Panbazar Overbridge, S.S. Road, Manipur, Mizoram, Choudhury
GUWAHATI-781 001 (ASSAM). Tel.:- 0361-2132204/5, Fax : Arunachal Pradesh,
0361-2732937, Email : [email protected] Nagaland and
Tripura
HYDERABAD Shri K. Insurance Ombudsman, Office of the Insurance Ombudsman, Andhra Pradesh, CV of Shri K.
Chandrahas 6-2-46, 1st Floor, Moin Court, A.C. Guards, Lakdi-Ka-Pool, Karnataka and Chandrahas
HYDERABAD-500 004. Tel : 040-65504123, Fax : 040-23376599, UT of Yanam - a
Email : [email protected] part of the UT of
Pondicherry
KOCHI Shri R. Insurance Ombudsman, Office of the Insurance Ombudsman, 2nd Kerala, UT of (a) CV of Shri R.
Jyothindranathan Floor, CC 27/2603, Pulinat Bldg., Opp. Cochin Shipyard, M.G. Road, Lakshadweep, (b) Jyothindranathan
ERNAKULAM-682 015. Tel : 0484-2358759, Fax : 0484-2359336, Mahe - a part of UT
Email : [email protected] of Pondicherry
KOLKATA Ms. Manika Datta Insurance Ombudsman, Office of the Insurance Ombudsman, West Bengal, Bihar, CV of Ms. Manika
4th Floor, Hindusthan Bldg. Annexe, 4, C.R.Avenue, Kolkatta - Jharkhand and Datta
700 072. Tel : 033 22124346/(40), Fax : 033 22124341, Email : UT of Andeman &
[email protected] Nicobar Islands,
Sikkim
LUCKNOW Shri G. B. Pande Insurance Ombudsman, Office of the Insurance Ombudsman, Uttar Pradesh and CV of Shri G. B.
Jeevan Bhawan, Phase-2, 6th Floor, Nawal Kishore Road, Uttaranchal Pande
Hazaratganj, LUCKNOW-226 001. Tel : 0522 -2231331, Fax :
0522-2231310, Email : [email protected]

MUMBAI Shri S. Insurance Ombudsman, Office of the Insurance Ombudsman, Maharashtra, Goa CV of Shri S.
Viswanathan 3rd Floor, Jeevan Seva Annexe, S.V. Road, Santacruz(W), Viswanathan
MUMBAI-400 054. Tel : 022-26106928, Fax : 022-26106052, Email :
[email protected]

OFFICE OF THE GOVERNING BODY OF INSURANCE COUNCIL

Shri M.V.V. Chalam, Secretary General The Secretary
3rd Floor, Jeevan Seva Annexe, 3rd Floor, Jeevan Seva Annexe,
S.V. Road, Santacruz(W), S.V. Road, Santacruz (W),
MUMBAI - 400 021 MUMBAI - 400 021.
Tel : 022-26106245 Tel : 022-26106980
Fax : 022-26106949 Fax : 022-26106949
Email : [email protected]
Web : www.gbic.co.in

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 MAX LIFE INSURANCE COMPANY LIMITED
Regd. Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi - 110 020
MAX LIFE TERM RIDER
1. THE CONTRACT Insured occurs from, or is caused by, either
directly or indirectly, voluntarily or involuntarily,
1.1 This Rider Contract (''Rider'') forms part of one of the following:
and supplements the Base Policy referred to in
the Schedule/ Endorsement (the ''Base Policy'').
The Proposal and other particulars (if any) (i) injuries resulting from riots, civil commotion,
together with the premium deposit and rebellion, revolution, war (whether war
declarations, received from the Proposer, form bedeclared or not); invasion or any war like
the basis of this Rider. In addition to the terms operations or terrorism or
and conditions of this Rider, this Rider is also
(ii) the Life Insured committing any breach of
subject to the terms and conditions of the Base
law; or
Policy. In the event of any inconsistency between
the terms and conditions of the Base Policy and (iii) the employment of the Life Insured
this Rider, the provisions of this Rider shall prevail in the police or armed forces or
with respect to the matters dealt with in this Rider. military/paramilitary service, naval, air
forces of any country in a state of war
1.2 The Company agrees to provide the benefits
(whether war be declared or not) or of armed
under this Rider while this Rider is in force.
conflict; or
2. BENEFITS
(iv) infection with HIV/ AIDS within 5 years from
2.1 On the happening of the Insured Event, the the later of Effective Date of this Rider or the
Company shall pay the benefits specified in the date of issue of this Rider.
Schedule/ Endorsement.
(v) Life Insured being under the influence of
2.2 The benefits under this Rider are in addition to the drugs, alcohol, narcotics or psychotrophic
benefits available under the Base Policy and/ or substance, not prescribed by a Registered
any other Rider(s) in force. Medical Practitioner
3. PERIOD OF COVERAGE 5.2 In addition to the above, this Rider is further
The Rider will remain effective from the Effective subject to the exclusions as provided in the Base
Date of this Rider and shall remain valid for Policy.
the period stated in the Schedule/ Endorsement 6. CHANGE OF OCCUPATION ETC.
unless terminated in accordance with Section 7
(seven) below. The Policy Holder is required to inform the
Company of any change in the occupation,
4. SUICIDE EXCLUSION profession, or hobbies of the Life Insured,
Notwithstanding anything to the contrary occurring during the term of the Rider, failing
contained herein, if the Life Insured commits which the Company may decline the Benefit
suicide, whether sane or not at the time, within in case the Insured Event arises out of such
one year from the later of : changed occupation, profession or hobbies. In
the event of such a change the Company, in its
(a) the Effective Date of this Rider; or absolute and sole discretion, reserves the right to
take such action as it may deem appropriate.
(b) the date of issue of this Rider, or
7. TERMINATION
the date of any reinstatement of this
(c)
Rider, This Rider shall automatically terminate :
then the coverage under this Rider shall come 7.1 if the Base Policy goes into Non-Forfeiture
to an end simultaneously with the occurrence of (as defined in the Base Policy), or has
such event, and the liability of the Company shall expired or lapsed or has been paid-up,
be limited to refund of the Premium(s) received, surrendered, cancelled or terminated for
without interest, less any expenses incurred by whatever reason; or
the Company.
7.2 on the death of the Life Insured, for
5. EXCLUSIONS whatever cause; or
5.1 Notwithstanding anything to the contrary stated 7.3 the period of coverage stated in the
herein, the Company shall not be liable on the Schedule/ Endorsement comes to an end
death of the Life Insured if death of the Life or on the anniversary of the Base Policy at
NB77
Max Life Insurance Co. Ltd
11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Phone 2561700 Fax 2389268 (From Delhi and Other cities: 0124) Customer Helpline: 1800-200-4006
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxlifeinsurance.com E-mail: [email protected]

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 which the Life Insured attains age sixty (60),
whichever is earlier; or

7.4 upon the Policy Holder's written request for

cancellation of the Rider.
Termination of this Rider shall be without
prejudice to any rights and liabilities which has
or have accrued prior to such termination. Any
payment or receipt, of any Premium(s) hereunder
subsequent to cancellation/ termination of this
Rider shall not create any liability, except that the
Company will refund such Premium(s), without
interest.
8. NOTICE AND ADMISSION OF CLAIM
The Company must be notified in writing within
ninety (90) days from the date of death of the
Life Insured. Failure to do so will invalidate a
claim. Admission of any claim will be subject
to production of such proof as the Company
may reasonably require being given within one
hundred and eighty (180) days from the date of
the death.
9. ASSIGNMENT
This Rider or the benefits under this Rider cannot
be assigned by the Policy Holder separately from
the Base Policy. If the Base Policy is assigned
by the Policy Holder, this Rider and the benefits
under the Rider shall also be assigned along with
the Base Policy.
10. REINSTATEMENT OF THE RIDER
At any time after the Rider has ceased to be valid
the Policy Holder may request for reinstatement of
the Rider. Upon such request, the Company may
at its sole discretion, reinstate the Rider, subject
to reinstatement terms as may be in force at the
relevant time.

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 Life Gain Plus ParticipatingTM
UIN No: 104N014V01
Participating
Policy/Proposal No: [ _________________ ]
Date of Illustration - Jul 29, 2012 6:48:39 PM
Insured TAPAS PAIK 868974403

Age at inception of Policy 40

Sex Male

Class Standard

Face Amount Rs 7,35,939

Bonus Option Paid Up Additions

Payment Mode Annual Direct Debit

Payment Period 6 Pay / 20 Years

PREMIUM SUMMARY

First Year Premium Renewal Premium

Basic Premium Rs 96,466.88 96,466.88

6 Year Term (UIN NO: 104B019V01) - Rs 1,00,000.00 -Rating 1.00 Rs 491.00 491.00

TOTAL Rs 96,957.88 96,957.88

Service Tax on Base Premium & Rider Premium(s), if any Rs 3,041.51 1,551.10

Total Premium (inclusive of Service Tax) Rs 99,999.39 98,508.98

Signature of Agent/Specified Person/Principal officer:___________________________________________ Policy Holders Signature:___________________________________________

This is only an Illustrative document. The Benefits if guaranteed, are clearly marked so. For variable benefits, investment growth rates of 6% and 10% are used as an illustration.
MAX LIFE INSURANCE CO. LTD, 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurgaon 122 002
Page 1 of 3

YEARLY DETAIL
The following ledger provides year by year illustrative figures for premiums required, for the policy that you have chosen.

General Details Guaranteed Non Guaranteed (Assumed rate of return on investments is 6% p.a.) Non Guaranteed (Assumed rate of return on investments is 10% p.a.)

Year Age Annual Death Cash Money Net Death Annual CV of Total Net Death Annual CV of Total
Premium Benefit Value Back Outlay Benefit Bonus Adds Cash Outlay Benefit Bonus Adds Cash
Value Value

( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs )
(BOY) (EOY) (EOY) (BOY) (EOY) (EOY) (EOY) (BOY) (EOY) (EOY) (EOY)

1 40 96,958 8,35,939 0 0 96,958 8,35,939 0 0 0 96,958 8,35,939 0 0 0

2 41 96,958 8,35,939 0 0 96,958 8,35,939 0 0 0 96,958 8,35,939 0 0 0

3 42 96,958 8,35,939 1,41,882 0 96,958 8,35,939 9,045 0 1,41,882 96,958 8,35,939 23,521 0 1,41,882

4 43 96,958 8,35,939 1,96,967 0 96,958 8,51,777 6,524 9,344 2,06,311 96,958 8,77,125 17,621 24,300 2,21,267

5 44 96,958 8,35,939 2,56,504 0 96,958 8,62,835 8,432 16,394 2,72,898 96,958 9,06,992 23,110 43,310 2,99,814

6 45 96,958 15,71,878 3,18,787 0 96,958 16,12,607 10,436 25,648 3,44,435 96,958 16,80,845 29,023 68,619 3,87,405

7 46 0 14,71,878 3,40,791 0 0 15,29,180 11,111 37,278 3,78,069 0 16,26,934 31,688 1,00,873 4,41,665

8 47 0 14,71,878 3,64,253 0 0 15,46,259 11,680 49,990 4,14,243 0 16,75,644 34,203 1,36,947 5,01,200

9 48 0 14,71,878 3,89,260 0 0 15,63,637 12,280 63,709 4,52,970 0 17,26,535 36,909 1,76,811 5,66,071

10 49 0 14,71,878 4,15,916 0 0 15,81,324 12,906 78,502 4,94,418 0 17,79,694 39,827 2,20,787 6,36,703

11 50 0 14,71,878 4,44,338 0 0 15,99,317 13,558 94,435 5,38,773 0 18,35,220 42,949 2,69,243 7,13,581

12 51 0 14,71,878 4,74,666 0 0 16,17,614 14,239 1,11,574 5,86,240 0 18,93,179 46,315 3,22,544 7,97,210

13 52 0 14,71,878 5,07,040 0 0 16,36,213 14,954 1,29,996 6,37,036 0 19,53,675 49,942 3,81,121 8,88,161

14 53 0 14,71,878 5,41,644 0 0 16,55,118 15,695 1,49,786 6,91,430 0 20,16,811 53,833 4,45,444 9,87,088

15 54 0 14,71,878 5,78,676 0 0 16,74,318 16,473 1,71,025 7,49,702 0 20,82,667 58,018 5,16,007 10,94,683

16 55 0 14,71,878 6,18,358 0 0 16,93,817 17,287 1,93,819 8,12,177 0 21,51,343 62,547 5,93,376 12,11,734

17 56 0 14,71,878 6,60,939 0 0 17,13,612 18,133 2,18,274 8,79,213 0 22,22,964 67,396 6,78,193 13,39,133

18 57 0 14,71,878 7,06,730 0 0 17,33,694 19,025 2,44,502 9,51,232 0 22,97,604 72,647 7,71,120 14,77,850

19 58 0 14,71,878 7,56,163 0 0 17,54,066 19,955 2,72,644 10,28,807 0 23,75,395 78,293 8,72,960 16,29,122

20 59 0 14,71,878 8,09,533 0 0 17,74,720 20,936 3,02,842 11,12,375 0 24,56,428 84,415 9,84,550 17,94,083

Maturity Value: Rs 8,09,533 Rs 11,33,311 Rs 18,78,498

NOTES: (BOY)-Beginning of Year Value (EOY) - End of Year value

Signature of Agent/Specified Person/Principal officer:___________________________________________ Policy Holders Signature:___________________________________________

This is only an Illustrative document. The Benefits if guaranteed, are clearly marked so. For variable benefits, investment growth rates of 6% and 10% are used as an illustration.
MAX LIFE INSURANCE CO. LTD, 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurgaon 122 002
Page 2 of 3
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Important Notes:

-- This is only an illustrative document. It does not purport to be a contract of insurance and does not in any way create any rights and/or obligations. Bonuses (if applicable and shown in the illustration) are not guaranteed, and bonus rates will be based on
the actual company experience from time to time.
-- Some of the benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance business. If your policy offers guaranteed returns then these will be clearly marked
"guaranteed" in the illustration table on this page. If your policy offers variable returns then the illustrations on this page will show the different rates of assumed future investment returns. These assumed rates of return are not guaranteed and they are not
the upper or lower limits of what you might get back, as the value of your policy is dependent on a number of factors including future investment performance.
-- Benefits secured under your Policy shall become payable provided all contractual premiums are paid as and when they are due. The illustrative benefits above assume that all the contractual premiums will be paid on the due dates.
-- Please refer to the product brochures, for understanding the product features and explanation of the terms used in this illustration.
-- Service Tax and Education Cess would be levied as per applicable laws.
-- You may be entitled to certain applicable tax benefits on your premiums and Policy benefits. Please note that all the tax benefits are subject to tax laws prevailing at the time of payment of premium or receipt of benefits by you.

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

Signature of Agent/Specified Person/Principal Officer: Policy Holders Signature:

Name and ID: Policy Holders Name:

Place: Date:

Date:

Company Seal:

MAX LIFE INSURANCE CO. LTD, 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurgaon 122 002

2010.1.2.8.6.57.13 401735939011103 100000061000000 100000180000 0 1

Page 3 of 3

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 INSURANCE PREMIUM RECEIPT
Policy Number: 868974403 Date: 29-Jul-2012
Name: Mr. Tapas Paik Base Life Insured: MR. TAPAS PAIK
Address: VIJAY RANJAN PAIK BESIDE Receipt Number: 868974403 /2012-13/01
HILL VIEW C OPP KAVERI Your Agent Advisor: Axis Bank Ltd Mango
HOTEL .,JAMSHEDPUR
East Singhbhum - 831018 General Office AXIS BANK LTD Mango
Jharkhand

Telephone: 9771183316,

Dear Mr. Tapas Paik,

Thank you for choosing Max Life Insurance. This is to acknowledge receipt of your premium as per details below.

Should you need any further assistance, please call our Customer Help Line -1800 200 4006 (Toll free from any network). You can
also email at [email protected]

Yours Sincerely,
for Max Life Insurance Co. Ltd.

Authorized Signatory

SUMMARY OF POLICY INFORMATION

Plan Premium paid For Due Date Frequency Effective Date
inclusive of of Coverage
Service Tax # ***
Max Life Life Gain Plus 20 Participating Plan 99,447.71 18-Jul-2012 Annual 18-Jul-2012
Max Life Term Rider (Par) 551.69 18-Jul-2012 Annual 18-Jul-2012
Total 99,999.40

Next Premium Due on - 18-JUL-2013

Note: || # Subject to realisation of monies. || *** All premiums will be eligible for tax benefits (under section 80C/80CCC/80D/37(1) of Income Tax Act 1961, as
per applicability) and subject to levies under prevailing Tax Laws (including Service Tax Laws). || As per the recent Union Budget 2012 proposals, effective April 1,
2012, your Policy may be entitled to certain tax benefits or subject to deductions . We request you to please consult with your tax consultant for more information.

Max Life Insurance Co. Ltd

11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Customer Help Line -1800-200-4006 (Toll free from any network)
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxlifeinsurance.com E-mail: [email protected]
Service Tax Regn. No. 443/ST/DIV-II/GGN/02
PRM20 V1.5 24052005
E.&O.E

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