Name of the Life Insured/Annuitant

Gender ^*

Male Female

Date of Birth (dd/mm/yyyy)^*

Present Age

Name of Proposer

Date of Birth of Proposer

Proposer Age

Do you want to backdate the policy?

Yes No

If yes, kindly specify the backdation date

Is the Life Insured covered under Kotak Life Insurance Policy? ^*

Yes No

Are you a Tobacco user ?

Yes No

Individual Policy Number

OR

Organization name

Are you a Non-Resident Indian? ^*

Yes No

For GST exemption, Bank Certificate is required stating amount paid in Convertible Foreign Exchange

Will you be able to furnish the Bank Certificate?

Yes No

Agent’s Branch Location ^*

Proposer’s Current Location ^*

Email

Mobile No

Occupation of Proposer

Occupation of Insured

Income of Proposer

Kotak Assured Savings Plan	Kotak Smart Life	Kotak Assured Income Accelerator	Kotak Premier Life	Kotak Premier Endowment	Kotak e-Term Plan
Policy Term^*		Policy Term^*		Policy Term^*	Policy Term^*	Policy Term^*
Premium Payment Term^*		Premium Payment Term^*		Premium Payment Term^*	Premium Payment Term^*	Premium Payment Term^*
Premium^*		Option for Bonus^*			Payout Option^*
		Sum Assured^*		Sum Assured^*
Cash Pay Out Frequency^*
	Fields marked ^* are mandatory