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Your premium (Inclusive of Service tax.)

Post-purchase benefits

Free Look period of 30 days

Allows you to return the policy and get your money back within 30 days

Lifelong benefits

Save Tax

Get tax benefits under the sections: 80C, 80D, 80DD, and 10(10D)

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Additional Riders

Enhance your plan with add-ons

Riders aren't available for this plan.

Add

Protection against 40 Critical illnesses

Get critical illness coverage of ₹
for just ₹

What are the benefits of Accelerated Critical Illness Option?

Get instant access to funds when you need them the most

Instant* disbursal of funds from your cover amount if diagnosed with any of the 40 listed critical illnesses, for immediate treatment.

^{*Valid after 90 days from date of commencement of risk or date of reinstatement}

1. Cancer of Specified Severity

2. Angioplasty

3. First Heart Attack – of Specified Severity

4. Open Heart Replacement or Repair of Heart Valves

5. Surgery toAorta Heart and Artery Benefit

6. Cardiomyopathy

7. Primary Pulmonary hypertension

8. Open Chest CABG

9. Blindness

10. Chronic Lung Disease

11. Chronic Liver Disease Major Organ Benefit

12. Kidney Failure Requiring Regular Dialysis

13. Major Organ/ Bone Marrow Transplant

14. Apallic Syndrome

15. Benign Brain Tumour

16. Brain Surgery

17. Coma of Specified Severity

18. Major Head Trauma

19. Permanent Paralysis of Limbs

20. Stroke resulting in permanent symptoms Brain and Nervous System Benefit

21. Alzheimer's Disease

22. Motor Neurone Disease with Permanent Symptoms

23. Multiple Sclerosis with Persisting Symptoms

24. Muscular Dystrophy

25. Parkinson’s Disease*

26. Loss of Independent Existence

27. Loss of Limbs

28. Deafness

29. Loss of Speech Others

30. Medullary Cystic Disease

31. Systematic lupus Eryth with Renal Involvement

32. Major Burns

33. Aplastic Anaemia

34. Poliomyelitis

35. Bacterial Meningitis

36. Encephalitis

37. Progressive supranuclear pals

38. Rheumatoid arthritis

39. Creutzfeldt - Jakob disease

40. Fulminant Hepatitis

Get a one-time lump sum payout upon critical illness diagnoses, rest payable on death

On the first diagnosis of any of the 40 specified critical illnesses, the payout for Critical Illness benefit will be made, and the balance life cover will be carried forward (with reduced future Premiums payable) and payable on death.

^{Note: In case of Angioplasty, the critical illness payment is limited to ₹5 Lakhs. The remaining CI Sum Assured payable on subsequent diagnosis of any one of the other specified Critical Illnesses.}

Add

VN03

Future Premium Waiver in case of Critical Illness or Disability

Pay just ₹

and CAB Sum Assured to <cabRiderSumAssured>

Max Life Comprehensive Accidental Death Benefit Rider (CAB)

Why is it recommended to add this rider?

India ranks number 1 in death due to road accidents with over 1,380 road crash injuries and 400 deaths every day in India; One road accident death every minute.

Source:-

http://www.bbc.com/news/world-asia-india-36496375

Life is full of uncertainties. You do not want an unfortunate accident to make a dent in your plans. We at Max Life Insurance understand this, which is why, we offer you Max Life Comprehensive Accidental Benefit Rider.

This rider provides additional protection against accidental death or dismemberment at a flat rate of Rs. 63 per Rs. 1 Lac of cover, for a maximum term of 35 years. (For further details, please refer to the Max Life Comprehensive Accidental Death Benefit, UIN -104B025V01, brochure)

What is covered under this Rider?

Death due to an accident

Dismemberment due to an accident

This would include

irrecoverable loss of entire sight in both eyes or
amputation or loss of use, of both hands at or above the wrists or
amputation or loss of use, of both feet at or above the ankles or
amputation or loss of use, of one hand at or above the wrist and one foot at or above the ankle

Rider coverage is only available till the premium payment term

Max Life Waiver of Premium Plus Rider (WOP)

Why is it recommended to add this rider ?

Every 33 seconds, one Indian dies due to heart attack; which is nearly two million heart attacks a year. It is startling that majority of the victims are youngsters.

Source:-

Source : Times of India, 19 May 2016

Cancer cases in India are expected to jump from around 14 lakh in 2016 to over 17.3 lakh by 2020, a growth of 20%.

Source:-

Source : Times of India, 19 May 2016

Max Life Waiver of Premium Plus Rider provides waiver of all future premiums in case of 11 critical illnesses (listed below) or dismemberment at a nominal cost. The maximum rider term is 35 years subject to a maximum maturity age of 70 years. (For further details, please refer to the Max Life Waiver of Premium Plus, UIN: 104B029V01, brochure)

What is covered under this Rider?

Dismemberment due to any cause

This would include

irrecoverable loss of entire sight in both eyes or
amputation or loss of use, of both hands at or above the wrists or
amputation or loss of use, of both feet at or above the ankles or
amputation or loss of use, of one hand at or above the wrist and one foot at or above the ankle

b. 11 Critical Illnesses covered are

1. Cancer of Specified Severity

2. First heart attack – of specified severity

3. Open chest CABG

4. Open heart replacement or repair of heart valves

5. Coma of specified severity

6. Kidney failure requiring regular dialysis

7. Stroke resulting in permanent symptoms

8. Major organ / bone marrow transplant

9. Permanent paralysis of limbs

10. Motor neuron disease with permanent symptoms

11. Multiple Sclerosis with persistency symptoms

Rider coverage is only available till the premium payment term

Add

TCPAB

Accidental death & disability coverage

₹ additional accident coverage
for just₹

and CAB Sum Assured to <cabRiderSumAssured>

Max Life Comprehensive Accidental Death Benefit Rider (CAB)

Why is it recommended to add this rider?

India ranks number 1 in death due to road accidents with over 1,380 road crash injuries and 400 deaths every day in India; One road accident death every minute.

Source:-

http://www.bbc.com/news/world-asia-india-36496375

What is covered under this Rider?

Death due to an accident

Dismemberment due to an accident

This would include

irrecoverable loss of entire sight in both eyes or
amputation or loss of use, of both hands at or above the wrists or
amputation or loss of use, of both feet at or above the ankles or
amputation or loss of use, of one hand at or above the wrist and one foot at or above the ankle

Rider coverage is only available till the premium payment term

Max Life Waiver of Premium Plus Rider (WOP)

Why is it recommended to add this rider ?

Every 33 seconds, one Indian dies due to heart attack; which is nearly two million heart attacks a year. It is startling that majority of the victims are youngsters.

Source:-

Source : Times of India, 19 May 2016

Cancer cases in India are expected to jump from around 14 lakh in 2016 to over 17.3 lakh by 2020, a growth of 20%.

Source:-

Source : Times of India, 19 May 2016

What is covered under this Rider?

Dismemberment due to any cause

This would include

irrecoverable loss of entire sight in both eyes or
amputation or loss of use, of both hands at or above the wrists or
amputation or loss of use, of both feet at or above the ankles or
amputation or loss of use, of one hand at or above the wrist and one foot at or above the ankle

b. 11 Critical Illnesses covered are

1. Cancer of Specified Severity

2. First heart attack – of specified severity

3. Open chest CABG

4. Open heart replacement or repair of heart valves

5. Coma of specified severity

6. Kidney failure requiring regular dialysis

7. Stroke resulting in permanent symptoms

8. Major organ / bone marrow transplant

9. Permanent paralysis of limbs

10. Motor neuron disease with permanent symptoms

11. Multiple Sclerosis with persistency symptoms

Rider coverage is only available till the premium payment term

PREMIUM

₹

Basics About You

Salutation

Mr.#1,Ms.#2

First Name

Please enter the value for First Name

Middle Name (Optional)

Please enter the value for middle name

Last Name

Please enter the value for last name

Father's/Husband's Name

Please enter the value for father's/husband's name

Date of Birth

Gender

Male#M,Female#F

Marital Status

Single#SNG,Married#MRD,Divorced#DVR,Widow(er)#WDW

Full name prior to marriage

Please enter the value for full name prior to marriage

Spouse's Occupation

Please enter the value for spouse's occupation

Total Insurance cover on spouse

Please enter the value for insurance cover on spouse

Spouse's Annual Income

Please enter the value for spouse's annual income

Spouse Policy Number with Max Life

Please enter the value for spouse's policy number (optional)

I am pregnant.

Number of months

<=6 months#Less,>6 months#More

Mobile Number

Please enter the value for mobile number

Alternate Mobile Number (Optional)

Please enter the value for alternate mobile number

Email Address

Please enter the value for email address

Nationality

Indian#I,NRI#O

Country of Birth

Passport Number

Passport Issuing Country

Current Country of Residence

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

Full Address in the country of Residence overseas

Telephone Number not pertaining to India

Date of Latest Entry to India

Country/Countries visited Frequently

Do you file for tax in more than one country?

Yes No

Please select one

PAN FTIN

Enter PAN Please enter correct PAN number

Foreign Tax Identification Number

Tax Filling Country

Add new

FTIN	Country

Type of Visa

Please enter the value

Visa Valid Till

Country of Residence as per Tax Laws

Please enter the value

Education

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

Car Registration Number (Optional)

Enter your car registration number

Use this information for all email communications

Your Communication Address

Your medical test will be conducted in the city mentioned below.

House No./Apt. Name/Society

Enter the value for permanent House No./Apt. Name/Society

Road/Area/Sector

Enter the value for permanent Road/Area/Sector

Landmark (Optional)

Enter the value for permanent landmark

State

City

Pincode

Enter the value for pincode

I have an

Aadhaar Card Number

Please enter valid aadhaar number

Aadhaar card enrollment number

Please submit physical enrolment copy after proposal form completion.

Enter Enrollment Number

My mobile number is updated in UIDAI and I want to proceed paperless journey through OTP authentication

Enter OTP

You have only 1 attempt

You have entered wrong OTP.Try resending OTP again.

Did not receive your OTP within 60 sec?

You have tried maximum times. Please try sending OTP.

You have exceeded maximum attempts, please proceed with physical aadhaar option

Please enter valid aadhaar number

Your Aadhaar is not linked with your mobile number.Please Proceed with physical aadhar submission.

Something went wrong. Please try after sometime.

My mobile number is not updated in UIDAI. I will submit the physical copy of aadhaar

Your Aadhaar has been successfully verified!!

Permanent Address is the same as my Communication Address

Permanent Address

Pincode

Enter the value for pincode

House No./Apt. Name/Society

Enter the value for permanent House No./Apt. Name/Society

Road/Area/Sector

Enter the value for permanent Road/Area/Sector

Landmark (Optional)

Enter the value for permanent landmark

State

City

Please enter a valid pincode

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Sorry,

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.

click on max life home page to view all products.

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click on max life home page to view all products.

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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

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

PROCEED RESELECT

Talk to our representative

Electronic Insurance Account will safeguard the insurance policy documnets of policy holders in electronic format.

Politically Exposed Persons(PEP) are individuals who are or have been intersted with prominent public functions, for example Heads/Ministers of Central/State government, Senior politicians, Senior government/Judicial/Military officers, Senior Executive of State Owned Corporations, important political party officials and immediate family members of persons (Spouse,Childern, Parents and Sibling, In-laws).

Employment and Insurance

Employment

Occupation Type

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

Industry Type

CRPF#CRP,Defence#DFN,Oil and Natural Gas#ONG,Merchant Marine#MEM,Mining#MIN,Others#OTH

Please specify occupation type

Please specify industry type

Name of the Employer

(auto search)

Job Title

Nature of Duties

E.g. Office job, Mechanical job, Sales job, etc.

Place of Posting

Rank

Which branch of armed forces are you in?

Are you involved in hazardous activity?

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

Yes No

Provide Details

Please Provide Details

Annual Income

Enter the amount as per your latest income proof

PAN (Permanent Account Number)

Please enter correct PAN number

Form 60

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

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.

Please Acknowledge this to Proceed

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?

Yes No

Name of Insurance Company

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

Policy Status

Issued#Issued,Pending#Pending,Lapsed#Lapsed

Type of Policy

Life#Life,Health#Health,CI(Critical Illness)#DD,Disablity#Accident

Add new

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?

Yes No

Name of Insurance Company

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

Policy Status

Declined for Medical Reasons#Declined for Medical Reasons,Extra Premium#Extra Premium,Coverage Reduction#Coverage Reduction,Postponed#Postponed

Type of Policy

Life#Life,Health#Health,CI(Critical Illness)#DD,Disablity#Accident

Add new

Name	Sum	Type	Status

We regret to inform that you are not eligible for the selected plan basis the income amount entered. If you have entered the income amount by mistake, please click ‘Reselect’ to reselect the income or type again.

RESELECT

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We regret to inform that we can offer a maximum Sum Assured of <sumAssured> to you with the filled income amount. The premium amount for that sum assured would get reduced to <premiumMonthly>.

ACCEPT RESELECT

You are eligible for a higher Life cover. Basis your profile and income, we are offering you a cover of <sumAssured>. Your premium will change to <premiumMonthly>.

You can also change any other cover amount.

You are eligible for a higher Life cover. Basis your profile and income, we are offering you a cover of <sumAssured>. Your premium will change to <premiumMonthly>.

You can also change any other cover amount.

Change Cover Continue with Existing Cover

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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.

click on max life home page to view all products.

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Sorry,

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.

click on max life home page to view all products.

Nominee Details

Title

Mr.#1,Ms.#2

First Name

Middle Name (Optional)

Last Name

Father's/Husband's Name

DOB of Nominee

Gender

Male#M,Female#F

Relation with Nominee

Spouse#SPOUSE,Parents#PARNTS,Others#OTHERS

Guardian Section

Full Name

Guardian Relation

Brother# BRO,Daughter#DGHTR,Parents#PARNTS,Sister#SISTER,Son#SON,Spouse#SPOUSE,Others#OTHERS

*In case you wish to add Multiple Nominee's then please write to Online@maxlifeinsurance.com and attach the form that can be downloaded from the Additional Nominee link in the footer.

Bank Details of Proposer

Bank A/C Number

Account Holder Name

IFSC Code

MICR Code

Bank and Branch Name

Type of Bank Account

CURRENT ACCOUNTS#Current,SAVING ACCOUNTS#Savings,OTHERS / FIXED / TERM ACCOUNTS#Others

IFSC code should be 11 and MICR should be 9 characters

Provide correct IFSC Code

Provide correct MICR Code

Provide correct IFSC and MICR Codes

Lifestyle & Well-being

Habit

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

Yes No

Type of Tobacco/Nicotine Products Consumed

Cigarette#Cigarette,Beedis#Beedis,Cigar#Cigar,Gutka#Gutka,Flavoured Pan Masala#FlavouredPanMasala,Khaini#Khaini

Type of Tobacco/Nicotine Products Consumed

Cigarette#Cigarette,Beedis#Beedis,Cigar#Cigar,Gutka#Gutka,Flavoured Pan Masala#FlavouredPanMasala,Khaini#Khaini

provide details

Frequency

Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally

Frequency

Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally

provide details

Quantity (In sticks/pouches)

Number of years

Add new

Type	Frequency	qunatity	noOfYears

Do you consume or have ever consumed alcohol?

Yes No

Type of alcohol consumed

Beer#Beer,Wine#Wine,Hard Liquor#HardLiquor

Type of alcohol consumed

Beer#Beer,Wine#Wine,Hard Liquor#HardLiquor

provide details

Frequency

Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally

Frequency

Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally

provide details

Quantity in ml

Number of years

Add new

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?

Yes No

Type of Drug Consumed

Cannabis#Cannabis,Marijuana#Marijuana,Ecstacy#Ecstacy,Heroin#Heroin,LSD#LSD,Amphetamines#Amphetamines,Other illegal drugs #Other illegal drugs

Type of Drug Consumed

Cannabis#Cannabis,Marijuana#Marijuana,Ecstacy#Ecstacy,Heroin#Heroin,LSD#LSD,Amphetamines#Amphetamines,Other illegal drugs #Other illegal drugs

provide details

Frequency

Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally

Frequency

Per Day#Per Day,Per Week#Per Week,Per Month#Per Month,Occasionally#Occasionally

provide details

Quantity in gms

Number of years

Add new

Type	Frequency	qunatity	noOfYears

Height & Weight

Height In

Feet-Inches#FT,Cms#CM

Height In

Feet-Inches#FT,Cms#CM

provide details

for e.g 5'06"

Weight (in Kgs)

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

Choose#choose,Exercise or Diet#E,Pregnancy#P,Medical condition#M,Others#O

provide details

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

Yes No

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?

Yes No

Family Member

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

Family Member

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

Age at Diagnosis

Disease/Medical problem

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

Disease/Medical problem

Add new

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?

Yes No

Provide details

Criminal Charges

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

Yes No

Provide details

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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.

PROCEED RESELECT

Talk to our representative

Your Insurance & Health Details

Insurance History

Do you have any life and/or Critical Illness Insurance plans/riders that is active or has ever been declined/postponed or accepted with modified terms?

Yes No

Name of Insurance Company

Policy No

Total Sum Assured

Policy Status

Issued#Issued,Pending#Pending,Lapsed#Lapsed,Declined for Medical Reasons#declined,Extra Premium#extra,Coverage Reduction#reduction,Postponed#postponed

Type of Policy

CI(Critical Illness)#DD,Cancer#Cancer

Add New

Name	Sum	Type	Status

Payor Details

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

Yes No

Relationship with payor

Spouse#Spouse,Parents#Parents,Other#Other

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.

Does payor have an

Aadhaar Card Number

Please submit the payor’s physical Aadhaar card copy after Proposal form completion

Enter aadhaar card number

Aadhaar card enrollment number

Please submit the payor’s physical Aadhaar enrolment copy after Proposal form completion

Enter Enrollment Number

Your Aadhaar has been successfully verified!!

First Name of Payor

Please enter First Name

Middle Name of Payor (Optional)

Last Name of Payor

Please enter Last Name

Gender

Male #M,Female#F

PAN Number

Please enter PAN number

User is not allowed to enter same PAN number as of Proposer

Date of Birth

Age Cannot be less than 25 Years.

Please enter DOB

Address

Please enter Address

Annual Income

Please enter Annual Income

CKYC

CKYC is a centralized repository of KYC records of customers in the financial sector with uniform KYC norms and inter-usability of the KYC records across the sector with an objective to reduce the burden of producing KYC documents and getting those verified every time when the customer creates a new relationship with a financial entity.

Know Your Customer

What is CKYC?

Do you have a CKYC number?

Yes No

CKYC Number

Mother's First Name

Mother's Last Name

City/Place of Birth

Address Proof

Select your address proof type

Passport#9,Driving License#10,Aadhaar/UID Card#13,Voter ID#17,Nrega ID#18,Others#20

Please Specify

Address proof Expiry Date (Expiry date should not be with next 30 days)

Identification Proof

Select your ID proof type

Pan Card#PC,Passport#PP,Driving License#DL,Voter ID#VID,Adhaar#Adhaar,NREGA ID#NI,Others#20

ID Proof Number

ID Proof Expiry Date

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Confirm Your Details

Basics About You

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

I have an

Do you have Aadhaar Card No/ Aadhaar Enrollment No

Communication Address

Permanent Address

Car Registeration Number

Employment Details

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?

Nominee Details

Title

Father's/Husband's Name

DOB of Nominee

Gender

Relation with Nominee

Relation

Guardian Name

Relation with Guardian

Bank Details

Bank A/C Number

Account Holder Name

IFSC Code

MICR code

Bank and Branch Name

Type of Bank Account

Lifestyle & Well-being

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

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 diagnosed with any form of internal or external congenital anomaly or defect i.e. any condition(s) which is present since birth, and which is abnormal with reference to form, structure or position?.

Details:

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

Your Insurance & Health 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?

Health

Have insured ever been investigated/Diagnosed or treated for any of the following: a. Have you suffered from or received investigation or treatment for any form of Cancer, sarcoma, tumor, or pre-cancerous conditions? b.Have any of your parents (below age 60 yrs), sisters or brothers suffered from any form cancer or tumours?

Is insured suffering from or ever suffered from , Hepatitis B, Hepatitis C, Liver disease, fatty liver due to alcohol, Barrett's Oesophagus, Crohn's Disease, Peptic Ulcer, Ulcerative Colitis, HIV/AIDs, Chronic Glomerulonephritis, Chronic Kidney Disease, Polycystic Kidney Disease, Anaemia?

Details:

Have insured suffered from or been investigated for any of the following in the past 12 months:

a. Recurrent cough, hoarseness of voice, or difficulty in swallowing for a Continuous period of 15 days?

b. Any persistent loss of blood or unusual discharge from any part of the body?

c. Weight loss more than 5 kg within 6 months?

d. Any ulceration, growth, nodule, cyst or lump in any part of the body?

Details:

Have insured undergone any of the listed investigations below or have had abnormal findings in the last 12 months (if applicable)

A. Ultrasound

B. Endoscopy/Colonoscopy

C. CT SCAN/MRI/PET SCAN

D. Biopsy/FNAC

E. PAP Smear

F. Mammography

G. Blood test for cancer diagnosis

Details:

Payor Details

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

CKYC

Do you have a CKYC number?

CKYC number

Mother's First Name,Last Name

City /Place of Birth

Address Proof

Address Proof Type

Please specify

Address Proof Expiry Date

Identification Proof

ID Proof Type

ID Proof Number

ID Proof Expiry Date

Add Waiver of Premium Plus Rider to get the maximum benefit out of your plan.

Add

Waiver of Premium Plus Rider

In case of critical illness or dismemberment, get the Premium waiver for a payment of just

71% customers who bought Term Plan also bought WOP

If you don't want to maximize your benefits..

Please continue without adding WOP rider

Max Life Waiver of Premium Plus Rider (WOP)

Why is it recommended to add this rider ?

Every 33 seconds, one Indian dies due to heart attack; which is nearly two million heart attacks a year. It is startling that majority of the victims are youngsters.

Source:-

Source : Times of India, 19 May 2016

Cancer cases in India are expected to jump from around 14 lakh in 2016 to over 17.3 lakh by 2020, a growth of 20%.

Source:-

Source : Times of India, 19 May 2016

Life Stage Benefit

Upgrade your cover amount as your Life progresses

Add 'Life Stage Benefit' option to increase your life cover in the same plan, without any additional requirement for documentation or medical tests. This benefit comes at 'No Extra Cost'!

Have any doubts? View details

I want to include Life Stage Benefit

The maximum additional coverage allowed is ₹50 Lakhs.

The option can be activated at three key milestone in life - marriage, child birth or home loan.

Continue with Life Stage Benefit

How does the Life stage benefit work ?

You have the option to increase the Sum Assured in future basis Life Stage events like Marriage, Child Birth or Home Loan.

This option has to be selected by you at time of inception of policy. The increase will only be applicable once You provide the intimation about the Life Stage change (along with the requisite proofs). When you increase cover at a later stage, the premium will go up.

The eligibility criteria for choosing this option are as follows:-

1. Sum Assured chosen by You at inception of the policy should be greater than or equal to ` 50 Lakhs.

2. Payment of three full annual premium equivalents from the time of policy issuance of reinstatement

3. Completion of three policy years from the time of policy issuance or reinstatement.

4. For "Pay Till 60" premium payment variant, this option can only be exercised before the completion of the premium payment term.

The following Life stage events are eleigible for increase in cover

Marriage (only 1 instance during the lifetime of policy) - 50% of Sum Assured not exceeding ` 50 Lakh

Child Birth (applicable for 2 children only) - 50% of Sum Assured not exceeding ` 25 Lakh, for each child birth

House loan(only 1 instance during the lifetime of the policy) - 50% of Sum Assured not exceeding ` 50 Lakh

Please note that the total increase in the Sum assured over the policy lifetime shall not exceed ` 50 Lakhs. Further, the increase in Sum Assured shall not be lower than ` 25 Lakhs. The increase in Sum Assured shall not be subject to any medical examination.

Please do note that the maxium additional coverage allowed is 50 Lakhs.

Schedule your medical test

Preferred date Date should start only after current date + 2 days and should not go beyond current date + 5 days

Preferred time

7:00 AM#7:00 AM,7:30 AM#7:30 AM,8:00 AM#8:00 AM,8:30 AM#8:30 AM,9:00 AM#9:00 AM,9:30 AM#9:30 AM,10:00 AM#10:00 AM,10:30 AM#10:30 AM,11:00 AM#11:00 AM

Visit type

Home Visit#Home Visit,Center Visit#Center Visit

Select your medical center

Tests to be conducted:

and

Carry original photo ID proof along with self attested photocopy of the diagnostic center

Take precautions and pre medical requirements as confirmed by us over the call and e-mail. The test may take 30 minutes to 3 hours depending upon the category of tests

CAT 2 and above need fasting. You must not consume any food or drinks(except water) for at least 12 hours prior to the test

CAT6 and CAT7 test need mandatory shaving of the chest (for males) along with TMT. Please wear fitting clothes and joggers/sport shoes as the test involves physical exercise

Mandatory reports will be shared by Max Life along with soft copy of policy pack after issuance. Medical centers can not share the medical reports

Photograph will be clicked during the examination

One Time Password (OTP) Authentication

You will receive a four digit verification code on and within the next 60 seconds.

This code will be valid for 30 min.

Enter OTP

You have a maximum of 5 attempts

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Please regenerate your verification code

Resending OTP

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Proposal Confirmation

Thank you for providing your details

Most of work is done,just 2 more things to do before we can process your application.

Please upload your documents & schedule a medical examination.

Upload Documents

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You have successfully scheduled your medical check-up. Now upload your documents..

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Upload documents

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You have successfully uploaded your documents and scheduled your medical check-up.

We have sent the details to your email and mobile via SMS.

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Congratulations!

You have successfully uploaded the documents.

We have sent the details to your email and mobile via SMS.

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E-bank statement

E_bank Statement enables the customer to submit their 6 months' bank statement online by using their net banking credentials (only for account where salary get credited). This works as an income proof against the application.

I hereby agree to use this option to submit my 6 month bank statement (where salary gets credited) to Max Life Insurance as an income proof for this application.

Note: Max Life may ask for additional income proof if required.

For more details click here

Upload Document

Browse to the document you intend to upload.

Upload Your Documents

Please upload the following self-attested documents to complete your application process. This is required to validate the information as provided by you in the application.

(10 MB limit per document. Only PDF, Tiff & JPEG allowed)

In case, you face any issues during upload, you may email the same to us at online@maxlifeinsurance.com

For proposer

Photograph(recent) tick

Upload Now

What is e-bank statement?

Perfios document is uploaded successfully.

Perfios document upload is not successful.

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Get details on your email and SMS to continue buying the policy later

Choose the Best Plan

Basic Life Cover SA ₹

Basic Life Cover + Monthly Income LA ₹

Basic Life Cover + Increasing Monthly Income IA ₹

Comprehensive Cancer Insurance

Upgrade to the best plan. Pay less, get more.

Basic Life Cover + Monthly Income

Basic Life Cover + Increasing Monthly Income

Calculate my term insurance premium

Calculate my term insurance premium

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Before you proceed, tell us a little bit about yourself

Max Life Online Term Plan Plus

Enhance your plan with add-ons

Protection against 40 Critical illnesses

Future Premium Waiver in case of Critical Illness or Disability

Accidental death & disability coverage

Future Premium Waiver in case of Critical Illness or Disability

Accidental death & disability coverage

Hello, need a few details before we proceed

Eligibility check!

You are eligible for this cover if:

Eligibility check!

You are eligible for this cover if:

Your Payment Summary

Your Payment Summary

Online Term Plan Plus

Complete your payment

Choose your Credit Card type

Important Message

Choose your Credit Card type

Choose your Debit Card type

Select your Bank

Important Message

Congratulations! You have successfully paid your premium of

Basics About You

Your Communication Address

Your medical test will be conducted in the city mentioned below.

Permanent Address

Employment and Insurance

Employment

Insurance History

Nominee Details

Guardian Section

Bank Details of Proposer

Lifestyle & Well-being

Travel and Adventure

Please select your activity

Habit

Height & Weight

Health

Cardio

Hormonal

Respiratory

Blood/Cellular

Digestive/Regulatory

Mental/Psychiatric ailment

Neural/Skeletal/Muscular

Infectious/Contagious

Family History

Criminal Charges

Your Insurance & Health Details

Health

Payor Details

Know Your Customer

What is CKYC?

Address Proof

Identification Proof

Confirm Your Details

Insurance History

Travel and Adventure

Height and Weight

Habit

Health

Family History

Criminal charges

Insurance History

Health

Add Waiver of Premium Plus Rider to get the maximum benefit out of your plan.

Basic Life Cover SA

₹

Basic Life Cover + Monthly Income LA

₹

Basic Life Cover + Increasing Monthly Income IA

₹