REQUEST FOR MAJOR REVIVAL OF POLICY

Details of Primary Life to be filled in Life Insured and Secondary Life to be filled in the Policyholders column where
Primary Life & Secondary Life are 2 different individuals

Primary Life Insured

Policy Number: for Joint Life policy:

Life Insured: Policy Owners Mobile No:

Client ID:
Proposer: Policy Owners Landline No:

Email ID:
c Do your bit for a greener world by switching to e-communication. Kindly tick if you would like to receive your communication through electronic mode
for all your policies.

If the policy is rejected at revival stage

Refund the premium to the bank account mentioned below.
(Please attach an original copy of cancelled cheque with your name and bank details pre-printed on it)

Name of the policy holder as per bank account

Bank Name & Address Account No
IFSC Code
MICR Code
Account Type Savings NRE* Others (if any)
*Refund to an NRE account shall be made only if premiums were received from an NRE account.
1) Name of:
Mr/Ms/Title Surname First name Middle name
Life Insured
Policyholder
(if different from life insured)
Nationality Life Insured: Policy Holder:
c Indian c NRI/PIO c Others_________ c Indian c NRI/PIO c Others_________
2) Occupation Details – Life Insured / Proposer (please tick whichever is applicable):-
a) Life Insured: c Professional c Self Employed c Housewife c Retired c Student c Salaried/Employed
c Others_______________
b) Proposer: c Professional c Self Employed c Housewife c Retired c Student c Salaried/Employed
c Others_______________
c) If Housewife, please specify source of income
3) Education Details – Life Insured / Proposer (please tick whichever is applicable):-
a) Life Insured: c Post-Graduate c Graduate c Professional c Diploma c HSC c SSC c Non-Matric
c Illiterate c Others_______________
b) Proposer: c Post-Graduate c Graduate c Professional c Diploma c HSC c SSC c Non-Matric
c Illiterate c Others_______________
4) Name & Address of the Present Life Insured: Policy holder (if diff. from Life insured)
Employer/Business:

a) Designation:
b) Nature of work:
c) Annual Income:
REQUEST FOR MAJOR REVIVAL OF POLICY

5) To be answered compulsorily Life insured Policy Holder

(if different from
Life insured)
a) Is the occupation of the life insured/proposer associated with any specific hazards c Yes c No c Yes c No
(which would render him/her susceptible to any injury or illness)?
b) Has there been any change in your occupation, nature of job, avocation or place of c Yes c No c Yes c No
residence since the date of signing the original application?
c) Is the life insured/proposer engaged in or intends to take part in any hazardous c Yes c No c Yes c No
hobbies/activities (which would increase the risk of any injury or illness)
d) Do you have any history of conviction under any criminal proceedings c Yes c No c Yes c No
in India or abroad?
e) Are you a Politically Exposed Person (these are the people who hold prominent public c Yes c No c Yes c No
function viz. Heads/Ministers of Central or State Govt., Senior Politicians,
Senior Govt. Judicial or Military Officials, Senior Executives of Govt. companies,
Important Political Party Officials and immediate family members of above persons)?
If the answer to any of the above questions is YES, kindly give details below:

6) Personal Statement regarding health of Life Insured / Policyholder Life insured Policy Holder
a Height (cms)
b Weight (kgs)
c Any history of weight loss or weight gain in last 1 year ? c Yes c No c Yes c No
If yes give details: ________________________________________________

7) Since the date of signing the original application, have you: Life insured Policy Holder
a Consulted a Medical Practitioner for any ailment /injury requiring treatment for c Yes c No c Yes c No
more than 7 days or remained absent from your place of work for more than
7 days, on health grounds or claimed against your health insurance policies?
b Undergone any cardiological / pathological or radiological tests? c Yes c No c Yes c No

8) Since the date of signing the original application, have you suffered from / are suffering from:
a High or low blood pressure, rheumatic fever, chest pain, myocardial infarction c Yes c No c Yes c No
or any other disease or disorder of the heart or arteries?
b Jaundice, anaemia, piles, ulcers, hernia, hydrocele, goiter, diabetes mellitus c Yes c No c Yes c No
or any other disease of the stomach, liver, spleen, gall bladder or pancreas?
c Asthma, bronchitis, pleurisy, tuberculosis or any other disease or disorder c Yes c No c Yes c No
of lungs?
d Paralysis, epilepsy, fits or any kind of nervous breakdown or any other disease c Yes c No c Yes c No
related to the brain or the nervous system or arthritic, skeletal or joint disorders?
e Any disease or disorder of ear, nose, eyes or throat, including defective sight c Yes c No c Yes c No
or hearing or discharge from ears?
f Cancer, leprosy, rheumatism, gout, enlarged glands or tumors? c Yes c No c Yes c No
g Any disease or disorder of kidney, prostate, urinary system or reproductive system c Yes c No c Yes c No
h Does the life insured have any physical defect / deformity illness / c Yes c No c Yes c No
impairment / disability not mentioned above?
i Is the life insured or partner HIV positive or suffering from AIDS, hepatitis, c Yes c No c Yes c No
gonorrhea, syphilis or any other venereal disease? Has the life insured
or partner ever been tested for HIV/hepatitis?
j Has the life insured ever had any accident requiring hospitalization or c Yes c No c Yes c No
undergone any treatment or operation for any ailment not mentioned above?
k Is the life insured pregnant now or has the life insured had any abortion or c Yes c No c Yes c No
miscarriage or caesarean section after the date of the proposal?
(For female lives only)
REQUEST FOR MAJOR REVIVAL OF POLICY

If the answer to any of the above questions contained in 7 and 8 above is YES, kindly give details below:
Sr. No. Nature of ailment /disease /condition etc Date of Fully recovered / still under Name, Address and
Diagnosis treatment Telephone Number of
the treating doctor

9) Existing/Proposed Insurance Details Life insured Policy Holder

a Has any proposal on your life/ application for reinstatement been postponed, c Yes c No c Yes c No
declined or accepted with extra premium or at modified terms by this company
or any other insurance company?
b Are there any existing policies, applications for revival of lapsed Policy or fresh c Yes c No c Yes c No
proposals on your life, under consideration of this Company or any other Insurer?
(If yes, please give details below)

Policy/Proposal Sum Assured Acceptance Terms Inforce/Proposal/

no. (Standard/Rated up/ Lapse (Mention
On Death ADB PDB CIB Deferred/Declined/ year of lapse/
Under Consideration) Revival applied for)

10) Additional details

Usage of Life Insured Proposer Average usage per day Reasons for giving up
the following (Answer as 'Yes'/ 'No') (Answer as 'Yes'/ 'No') (past/ present) (if applicable)
Current Past Current Past Life Insured Proposer Life Insured Proposer
Alcohol
Tobacco
Any Narcotics
SECTION 41 OF THE INSURANCE ACT, 1938 (4 OF 1938): 1) No person shall allow or offer to allow, either directly or indirectly,
as an inducement to any person to take or renew or continue an insurance in respect of any kind of risk relating to lives or property in
India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person
taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectuses or tables of the insurer: Provided that acceptance by an insurance agent of commission in connection with a policy of life
insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this
sub section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide
insurance agent employed by the insurer. (2) Any person making default in complying with the provisions of this section shall be
punishable with fine which may extend to five hundred rupees.

DECLARATION BY THE LIFE INSURED AND POLICYHOLDER (if different from the Life insured)

I/We declare that I/We have answered the questions in this Policy Revival Form after fully understanding the nature of the questions and
the importance of disclosing all information while answering such questions. I/We further declare that the answers given by me / us to all
the questions in this form are true and complete in every respect and that I/We have not withheld any material information or suppressed
any fact. I/We undertake to notify Kotak Life Insurance of any change in the state of health of the life insured or as to his/her occupation
or any decisions about his/her existing policies or proposals subsequent to the signing of this form and before the acceptance of the risk
by Kotak Life Insurance.
I/We further declare that this Policy Revival Form shall also be the basis of the contract of insurance and if any untrue statement is
contained in this form, the Company shall have the right to vary the benefits which may be payable and further if there has been a non-
disclosure of a material fact the policy may be treated as void and all premiums paid under the policy may be forfeited to the Company as
per the provisions of Section 45 of the Insurance Act 1938, as amended from time-to-time. I/We hereby authorise the employer, doctor
or hospital of the life insured to divulge to the Company any information required by them in connection with the policy contract. I/We
understand that the contract shall be governed by the provisions of the Insurance Act, 1938, as amended from time to time and that the
policy shall not be revived until the Company's written acceptance of this application is received.
REQUEST FOR MAJOR REVIVAL OF POLICY

Life insured Proposer

Date: Place: Date: Place:

Signature / Left Thumb impression Signature / Left Thumb impression

* If a person other than the Policy Holder fills the form, then the person filling this policy revival form on his / her behalf must sign the following declaration:
DECLARATION BY THE PERSON FILLING IN THE FORM
(For forms filled in by a scribe or for forms signed in vernacular languages)

I _________________________________________, having known the Policy Holder for a period of __________ declare that I have
explained the nature of the questions contained on this application to the Policy Holder. I have also explained that the answers to the
questions form the basis of the contract of insurance between the Company and the Policy Holder and that if any untrue statement is
contained therein the Company shall have the right to vary the benefits which may be payable and further if there has been a non-
disclosure of a material fact the policy may be treated as void and all premiums paid under the policy may be forfeited to the Company as
per the provisions of Section 45 of the Insurance Act 1938, as amended from time-to-time.
Address of scribe:

Date:

Place: Signature of the Scribe

Note:
1) Maximum period of revival for your policy shall be as per below, as applicable:
(a) 5 years from the date of lapsation of the policy for policies issued before 1st July 2006
(b) 2 years from the date of lapsation of the policy for policies issued on or after 1st July 2006 for Non-Unit Linked Plans
(c) 2 years from Paid To Date or 3 years from Risk Commencement Date, whichever is later, from the date of lapsation of the policy for
policies issued on or after 1st July 2006 for Unit Linked Plans prior to IRDA Discontinued Linked Insurance Policies Regulations, 2010
(d) 2 years from Discontinuance date or 5 years from Risk Commencement Date, whichever is earlier, for Unit Linked Plans launched in
accordance to IRDA Discontinued Linked Insurance Policies Regulations, 2010
(e) 2 years from Discontinuance date or 5 years from Risk Commencement Date, whichever is later, for Unit Linked Plans launched in
accordance to Linked Insurance Products, 2013 Guidelines.
2) Major revival formalities shall be applicable for policies in major lapse status, i.e. 6 months from the premium due date for policies in Lapse,
ACM, ANM, RPU status and 6 months from the discontinuance date for policies in Discontinuance mode
3) For revival premium received via Cash mode or Local Clearance Cheque / Demand Draft, the applicable NAV shall be the closing NAV of the
same business day on which the Underwriting decision is received before the cut-off time of 3pm.
4) For revival premium received via Cash mode or Local Clearance Cheque / Demand Draft, the applicable NAV shall be the closing NAV of the
next business day on which the Underwriting decision is received after the cut-off time of 3pm.
5) For revival premium received via Outstation clearance cheque / Demand Draft, the applicable NAV shall be the closing NAV on which
underwriting decision is received or the premium amount is realized, whichever is later, as per cut-of time of 3pm.
6) For revival of policies in discontinuance mode, the discontinuance charges deducted from the fund will be added back to the fund value.
7) Post review of the Major revival form, client may have to undergo medical tests/ physical examination (at his/her own cost).
8) NAV will be allocated of the day on which underwriting decision is taken or the premium amount is realized, whichever is later.
9) This policy shall be revived only post fresh underwriting of the case and fulfillment of all requirements as may be called for by the Company.
The policy shall be revived only after acceptance of the risk by Underwriters of the Company and due communication of the same to the policy
holder after clearance of the cheque. Till then the policy shall not be re-instated.
10) Kindly note that the amount paid by you towards revival of your policy shall lie unadjusted in your policy suspense account and your
insurance cover shall not be reinstated unless the requirements are fulfilled. Further, if the required documents are not received within 45 days
from the receipt of the Major Revival Form, the amount lying in your policy suspense account shall be refunded back to you without
reinstating your policy. Please note, the unadjusted premium shall not carry any interest.
11) In order to abide by the Foreign Account Tax Compliance Act (FATCA), kindly submit a Insurance FATCA Declaration, separately, if the
answer to any of these questions is a ‘yes’: (i) Are you a citizen of any other country apart from India (dual or multiple citizenship); (ii) Are you
a resident (for tax purposes) of any other country other than India; (iii) Do you hold a green card of USA or any similar card for any other
country?
I/We confirm that I/we shall report any future changes in my/our tax status to Kotak Life Insurance within 30 days of such change. I/We also
confirm that until I/we provide a written intimation about any such changes, Kotak Life Insurance may presume that there is no change in
my/our tax residency status and consider my/our earlier submitted declarations, if any, as valid. I understand that for any queries about
my/our tax residency, I/we have to consult my/our own tax consultant.
REQUEST FOR MAJOR REVIVAL OF POLICY
Annexure
Guidelines to fill the Major Revival Form
A] Mandatory Fields:
1] Contact number:
• Mobile / residence
2] Occupation, Avocation & Residence
• Designation
• Nature of work
• Annual income
• If associated with occupational hazards – relevant Kotak Life Insurance Occupation Questionnaire to be provided if engaged in or intending to take part
in hazardous hobbies/activities – Please specify
3] Education:
• Provision of a Income Tax Return ≥ 2 lacs or professional qualification certificate may help in the granting of higher non medical limits
4] Personal Details
• If the life insured is minor - Height/weight to be correctly filled
• Proposers height/weight – if WOP Rider applied for or if the plan is Long Life Secure Plus or Headstart Future Protect Joint Life or
Wealth Insurance Plus
5] Medical questions
• To be answered in Yes or No Format and wherever Yes – relevant details to be provided
• Proposer column to be filled – If WOP Rider applied for or if the plan Long Life Secure Plus or Headstart Future Protect Joint Life or
Wealth Insurance Plan
6] Existing/Applied policies with Kotak Life Insurance or other Insurers: Give details as follows
• Policy no
• Plan details – Sum Assured of base plan and rider if any
• Acceptance Terms –[standard or rated up or declined or deferred or not completed]
• Status – [In force / Lapsed/applied for revival etc.]
7] Habits: (Tobacco/ Alcohol/ Narcotics): If usage of any of the same is “Yes” then please specify:
• Form of consumption – [cigarettes, beedi, pan, Guthka, Beer, Hard liquor]
• Usage per day – [sticks,grams,packets,ml,units,pints]
• Duration
8] If policy holder has signed in vernacular/thumb impression then provide – SCRIBE DETAILS
• Name of scribe
• Complete Address
• Sign
• Date and place of signing
B] Additional Information
1] Alterations:
Alteration in any of the following would require submission of a documentary proof along with request for a change
• Name
• Date of birth
• Residential Address
• Signature [dual sign format with previous and current signatures]
• Education
• Nominee
2] Income Proof Documentation:
a] If the total cover on the life insured including the existing and applied policies with Kotak Life Insurance is more than 15 lacs then latest income proof
would be required
b] If total premium paid either as
• Proposer
• Life insured
• Third Party Premium Payer
for all proposals/ policies with Kotak Life Insurance put together is one lakh or more, latest income proof is required
c] If total premium paid either as
• Proposer
• Life insured
• Third Party Premium Payer
for all proposals/policies with Kotak Life Insurance put together is 50 thousand or more, copy of pan card of premium payer is required
3] NRI Clients : Please provide:
• NRI questionnaire
• Copy of all the printed pages of the passport if not submitted earlier
• Current residential address in India
4] Cancellation/overwriting on the MRF – Should be countersigned near the place of overwriting
The above annexure is intended to help in the filling of the Major Revival Form and to ensure its completeness in all respects. It does not form a part
of the revival application and should not be scanned along with the application.
Kotak Mahindra Life Insurance Company Ltd. IRDA Regn no.107, CIN: U66030MH2000PLC128503, Regd Office: 2nd Floor, Plot # C-12, G-Block, BKC,
Bandra (E), Mumbai - 400 051. For any correspondence kindly contact us at : Kotak Infiniti, 7th Floor, Building No. 21, Infiniti Park, Off Western Express Highway,
Goregaon Mulund Link Road, General A.K. Vaidya Marg, Malad (E), Mumbai – 400 097. (+9122) 6605 7777{D} 66200550 {F}
http://insurance.kotak.com Toll Free No: 1800 209 8800
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ACKNOWLEDGMENT
We acknowledge the receipt of request of Revival of Policy no.: __________________.
Branch Name Documents received with this request

Date Time
Name of branch co-ordinator Signature of branch co-ordinator
Kotak Mahindra Life Insurance Company Ltd. IRDA Regn no.107, CIN: U66030MH2000PLC128503, Regd Office: 2nd Floor, Plot # C-12, G-Block, BKC,
Bandra (E), Mumbai - 400 051. For any correspondence kindly contact us at : Kotak Infiniti, 7th Floor, Building No. 21, Infiniti Park, Off Western Express Highway,
Goregaon Mulund Link Road, General A.K. Vaidya Marg, Malad (E), Mumbai – 400 097. (+9122) 6605 7777{D} 66200550 {F}
http://insurance.kotak.com Toll Free No: 1800 209 8800
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