Project

1. Name of the Prospect/Policyholder:
Age & Gender:
Name of the Life Assured:
Age & Gender:
Policy Term:
Premium Payment Term:
Amount of Installment Premium:
Mode of payment of premium:
Name of the Product:
Max Life State:
Unique Identification No:
Tag Line:
GST Rate (Base Policy, First Year):
Policyholder Residential State:
Max Life Smart Wealth Plan
A Non-Linked Non Participating Individual Life Insurance Savings Plan
Mr.
35 Years, Male
Mr.
35 Years, Male
10 Years
10 Years
`1,04,500
Annual
104N116V03
Uttar Pradesh
Uttar Pradesh
4.50%
Proposal No:
Policy Details
Policy Option Lump Sum Sum Assured (in Rs.)
Sum Assured on Death (at inception of the policy) (in Rs.)
11,00,000
11,00,000
This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.
Income Period, if applicable:
Mode of Income, if applicable:
NA
NA
GST Rate (Base Policy, Subsequent Year):
GST Rate (Rider, First Year):
GST Rate (Rider, Subsequent Year):
2.25%
NA
NA
BENEFIT ILLUSTRATION
[Date and Time of Illustration – 28 January 2021, 11:00 AM]
Annual Income Amount: NA
Rider Details
Accidental Death & Dismemberment (ADD) Rider Term
Term Plus Rider Term
Waiver of Premium (WOP) Plus Rider Term
COVID19 One Year Term Rider Term
Critical Illness and Disability Rider - Rider Premium Payment Term and Rider Term
NA
NA
NA
NA
NA
Accidental Death & Dismemberment (ADD) Rider Sum Assured (in Rs.)
Term Plus Rider Sum Assured (in Rs.)
COVID19 One Year Term Rider Sum Assured (in Rs.)
Critical Illness and Disability Rider - Coverage Variant
Critical Illness and Disability Rider - Rider Sum Assured
NA
NA
NA
NA
NA
Premium Summary
Base Plan
Accidental Death &
Dismemberment Rider
Term Plus
Rider
Waiver of Premium
Plus Rider
COVID19 One Year
Term Rider
Critical Illness and
Disability Rider
Total Installment
Premium
Installment Premium without GST (in Rs.)
Installment Premium with first year GST (in Rs.)
Installment Premium with GST 2nd year onwards (in Rs.)
1,00,000
1,04,500
1,02,250
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1,00,000
1,04,500
1,02,250
UIN: 104N116V03 Page 1 of 2
Max Life Insurance Company Limited having its Corporate Office at 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurugram – 122002

2. (Amount in Rupees)
Signature / Thumb Impression / Electronic Signature of
Agent/ Intermediary / Official
Signature / Thumb Impression / Electronic Signature of
Prospect/ Policyholder
Date:
Place: Date:
I, ……………………………………………. (name),have explained the premiums, and benefits
under the product fully to the prospect / policyholder.
1/28/21
1/28/21
I, ……………………………………………. (name), having received the information with respect
to the above, have understood the above statement before entering into the contract.
This system generated benefit illustration shall be treated as signed by me.
Notes:
• Annualized Premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any, and Goods and Service Tax.
• Total Annual Premium includes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any but excludes Goods and Service Tax.
• Refer Sales literature (Prospectus) for explanation of terms used in this illustration.
Policy Year
Single/ Annualized
Premium
Total Annual Premium
Guaranteed Non Guaranteed
Accrued Guaranteed
Additions
Other Benefits, if any
(Guaranteed Sum
Assured at Maturity)
Maturity Benefit Death Benefit
Min Guaranteed
Surrender Value
Special Surrender Value
1 1,00,000 1,00,000 - - - 11,00,000 - -
2 1,00,000 1,00,000 - - - 11,00,000 60,000 84,000
3 1,00,000 1,00,000 - - - 11,00,000 1,05,000 1,47,000
4 1,00,000 1,00,000 - - - 11,00,000 2,00,000 2,80,000
5 1,00,000 1,00,000 - - - 11,00,000 2,50,000 3,96,750
6 1,00,000 1,00,000 - - - 11,00,000 3,00,000 5,08,260
7 1,00,000 1,00,000 50,000 - - 11,00,000 3,65,000 6,58,010
8 1,00,000 1,00,000 1,00,000 - - 11,48,720 5,90,000 8,42,240
9 1,00,000 1,00,000 1,50,000 - - 13,48,650 8,55,000 10,62,360
10 1,00,000 1,00,000 2,00,000 11,00,000 13,00,000 15,64,500 9,60,000 13,00,000
UIN: 104N116V03 Page 2 of 2
85,35,10,1100000,0,100000,M,c85
Max Life Insurance Company Limited having its Corporate Office at 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurugram – 122002