PSRF718619011751 | Comp/Jan/Int/4746

Moral Hazard Questionnaire

Thank you for applying for a policy from HDFC Standard Life Insurance Co. Ltd. To enable us to assess your application, please fill and
sign (applicant) this document.

Policy No.:
Application No.
Name of the Life to be Assured

Please let us know the details of dependents in your family.

Relationship Father Mother Spouse Children

Dependent (Mention Yes or 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 financially dependent on you - Yes / No? (if yes, please fill section A & B along with other questions)
A.) Please let us know the financial obligation in choosing a person other than an immediate family member as nominee/beneficiary:

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B.) Please specify the exact reason for not choosing an immediate family member as nominee/beneficiary:

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2. Are you obliged to support and maintain the named nominee - Yes / No? :---------------------------------------------------------------------

3. Any other reason to support choosing the named nominee? Please specify:-------------------------------------------------------------------

4. Are you aware of the legal consequences of nominating a person other than an immediate family member--------------------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 ------------------------------------------------------------------ ------------------------------
(**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 Standard Life Insurance Co. Ltd. and that failure to disclose any material fact known to me
may invalidate the contract. Signature/thumb impression:

DD/MM/YYYY
Date: __________________

Place: __________________

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.
Name ___________________________________________________________________ SIGN HERE

Address: _________________________________________________________________

DD/MM/YYYY
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 Standard Life Insurance Company Limited (“HDFC Life”). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: Lodha Excelus, 13th Floor, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, call us on 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@hdfclife.com | NRIservice@hdfclife.com (For NRI customers only) | Visit -www.hdfclife.com
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