PSRF718619011751 | Comp/Jan/Int/4746
Moral Hazard Questionnaire
Thank you for applying for a policy from HDFC Life Insurance Co. Ltd. To enable us to assess your application, please fill and sign
(applicant) this document.
Policy No.:
Application No. 1100116034971
Name of Life to be Assured. NARENDRA AHUJA
Please let us know the details of dependents in your family.
Relationship Father Mother Spouse Children
Dependent (Mention Yes or No) NO NO NO NO
You have nominated a person who does not fall under the relationships mentioned above.
Hence, please answer the following questions:
1. Is the nominee/beneficiary financial dependent on you - Yes / No? (if yes, please fill section A & B along with other questions) : NO
2. Are you obliged to support and maintain the named nominee - Yes / No? :
NO
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3. Any other reason to support choosing the named nominee? Please specify:
NA
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4. Are you aware of the legal consequences of nominating a person other than an immediate family member
YES
--------------------Yes / No?
(if no, please get in touch with your Financial Consultant for more clarity and provide a fresh MHQ)
5. Please confirm exact relationship** of nominee
Daughter In-law
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( **Mandatory if nominee relationship is captured as "others" in proposal form.)
Declaration of Life to be Assured:
I agree and understand that the information given herein is true and complete in all respects and will form an integral part of the proposal made by me for an insurance policy
from HDFC Life Insurance Co. Ltd. and that failure to disclose any material fact known to me may invalidate the contract.
Signature/thumb impression:
NARENDRA AHUJA
OTP_Time_Stamp: 2025-02-22 [Link]
Indore
OTP_Value: 62290
Date:
22/2/2025
Place: Indore
_______________________
In the case of thumb impression/ signature in vernacular language:
In case of thumb impression of the Life to be Assured, the same should be attested by a person of standing whose identity can be easily established, but unconnected with the
Company and this declaration should be made by him.
I hereby declare that I have explained the contents of this form to the Life to be Assured in _________ language and have truthfully recorded the answers provided to me and
that the Life to be Assured has signed /affixed thumb impression(s) above after fully understanding the contents thereof.
SIGN HERE
Name _____________________________________
Address: ________________________________
Date: ___________ Place: __________ Signature
Explanation:
1. Financial obligation - An obligation to pay money to another party 2. Obliged - To do something because of a law
Disclaimer:
Nominee relationship mentioned "others" will not be accepted. Unclear and inadequate information to support choice of nominee will lead to rejection.
HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm | Email –
service@[Link] | nriservice@[Link] (For NRI customers only) Visit – [Link]
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