Special Mortal Hazard And KYC Verification Report(UWN024)
Sum Assured*
Name of Proposer
SUC
Region
Channel
PC Name
MHR is based on your verification of identity of person, age, address, occupation, health, income and social and financial status. All the facts mentioned in the report must be adequately verified by you. If proposer and the life assured are the different then MHR should cointain information about both the persons. Where the Premium is paid by the person other than proposer, the financial details of premium payer is to be verified and mentioned in the MHR.
A.Please mention whether this report contains details of
Please give details of your meeting.(please mention names of the person in case report is about multiple persons)
Name of Person
1.Did you personally meet him/her
If any of the above answer is 'NO', then please mention as to how, you have gathered the information about him/her.
Date of Meeting *
Place of Meeting *
B.Verification of Personal and Financial Details
Please ensure that all the facts are verified on the basis of origial documents
DOB And Age of Life Assured *
Age
Photo Identification *
Mention Full Address as Verified *
Did he/she appear over aged *
Occupation *
Professional Qualification *
Does the Proposer/Life assured/Premium payer belong to PEP Category *
If yes, please provide the details....
Details of Income and Assets and Liabilities on the basis of your verification and assessment
Please mention whether following details pertain to
|
Income(Last FY) |
Amount (Rs.) |
Assets |
Value (Rs.) |
|---|---|---|---|
| Salary | Fixed Deposit/Bonds | ||
| Business and Profession | Bank A/c Bal. | ||
| Agriculture | Equity/Shares | ||
| Family Income | Agricultural Land | ||
| Other Income | Self owned Building/Flat | ||
| Total Income | Total Assets |
|
Liabilities |
Value (Rs.) |
|---|---|
| Loan | |
| Mortgage | |
| Total Liability |
You may highlight any specific information about the income and occupation of the person and documents seen by you.
C. Specific verification of income and occupation in following cases
In case of occupation being business or profession or self employment :
Describe nature and duration of business/Occupation/Profession :
Name and Address of Employer or Firm/Company (owned or associated with) :
Invest, Turnover and profit from Business/Occupation/Profession in last three years :
|
|
Year - |
Year - |
Year - |
|---|---|---|---|
| Investment | |||
| Turnover | |||
| Profit |
In case of occupation being agriculture :
Describe Land Holding, crop pattern, Share of Proposer/Premium payer, whether land is held in joint ownership/tenancy and Income from agriculture.:
| Corp Pattern | |
| Income in last Three years | |
| Land Holding (Acres) | |
| No. of owners(In case of land owner) | |
| Ownership | |
| Share in land(Acers) |
Please mention the documents seen to verify Agricultured income *
Describe income from other sources - rent, interest etc. Please mention the documents seen to verify Other income
D. While Discussing health and medical status did you see or discover any physical or mental deformity or history or current status or immidiate plans of medical treatment/disease or surgery/hospitalization *
If yes, please provide the details..
E. Is there any other detail with respect to the client which would add to the risk, legally (criminal proceedings etc) or from the point of view of KYC or AML guidelines? *
If yes, please provide the details..
F. Opinion and Recommendations * :(Mandatory) It must include your opinion with regard to adequacy of cover amount applied for, capacity to pay regular premium, adequacy of source of funding, payment of premium from own bank account, and insurability and acceptability of the risk *
Please elaborate the above points adequately in case the proposer/life assured in finically depended(student, housewife etc.), widows or premium is funded by a person other than the proposer. You may use additional sheets if required to elaborate your views. You may also attach documents to support the evidence.
I have personally verified the details mentioned in this report and declare that the details are true. I understand that the person who is authorised to give this report as per the MHR circular is primarily responsible for the facts presented in this reports, even if other persons have put their signature along with him/her in this report.
SUC :
MHR Authority as per SUC :
Place :
Date :
Capture Photo of Proposer
Name And Designation :