Sr.No.

2018/
APPLICATION FORM
UTI-Unit Linked Insurance Plan (UTI-ULIP) TIME STAMP

Registrar Sr. No.

(Please read instructions carefully before filling the form and use BLOCK LETTERS only) [Fields Marked with (*) must be Mandatorily filled in] Ê
distributor information (only empanelled Distributors/Brokers will be permitted to distribute Units)  (Refer instruction ‘h’) BDA / CA Code
ARN / Name of Financial Advisor Sub ARN Code Sub-Code / M O Code EUI No.@ UTI RM No.
RIA code^ Bank Branch Code

ARN-121213 Anilmohan.S E 189089

^ By mentioning RIA code, I/we authorise you to share with the Investment Adviser the details of my/our transactions.
upfront Commission shall be paid directly by the investor to the amfi/NiSm certified uti mf registered distributors based on the investors’ assessment of various factors including
the service rendered by the distributor.
@ I/We confirm that the EUIN box is intentionally left blank by me/us as this is an “execution-only” transaction without any interaction or advice by the distributor personnel
concerned or notwithstanding the advice of in-appropriateness, if any, provided by such distributor personnel and the distributor has not charged any advisory fees for this
transaction. ( Please tick and sign below when EUIN box is left blank). (refer instruction ‘w’)

Ê
Signature of Applicant / Guardian

TRANSACTION CHARGES TO BE PAID TO THE DISTRIBUTOR (Please tick any one of the below.) (Refer instruction ‘i’)

I AM A FIRST TIME INVESTOR IN MUTUAL FUNDS I AM AN EXISTING INVESTOR IN MUTUAL FUNDS

OR
` 150 will be deducted as transaction charges per Subscription of ` 10,000 and above ` 100 will be deducted as transaction charges per subscription of ` 10,000 and above

Existing Unit Holder information  If you have an existing folio no. with PAN & KYC validation, please mention your Folio Number  here:

applicant’s personal details Mr. Ms. Mrs. M/s.

Name of Applicant / Minor (above 12 years of age) (as appearing in Aadhaar) (Refer Instruction ‘r’)

F I R S T M I D D L E

L A S T Date of Birth of Minor / Applicant d d m m y y y y Mandatory

Applicant’s Address (Do not repeat the name) Name & Address of resident relative in India (for NRIs) (P.O. Box No. is not sufficient)

Village/Flat/Bldg./Plot*

Street/Road/Area/Post

City/Town* State Pin*

Overseas Address (overseas address is mandatory for nri / fPi applicants in addition to mailing address in India)

City*

State Country* Zip/Pin*

Name iN full of the fatheR (OR) motheR (oR) guaRdiaN (iN CaSe of miNoR)$$ (as appearing in id proof given for Kyc) / huSbaNd of the appliCaNt Mr. Ms. Mrs.

F I R S T M I D D L E L A S T

$$  Proof of date of birth and proof of relationship with minor to be attached or else sign the declaration on the reverse.  (Refer instruction ‘f’)

Address of the Father / Mother / Guardian of Minor (if different from address mentioned above) (Post box no. alone is not sufficient)

City*

State Country* Pin*

*PAN/PEKRN$ of Applicant / Minor / Father / Mother / Guardian (whose particulars are furnished in the form) Please ()

Enclosed copy of PAN/PEKRN Card/ID Proof Copy KYC Compliance Proof*  AadhaAr No.

*PAN No. OF HUF / SPOUSE Enclosed copy of   PAN/PEKRN Card/ID Proof Copy    KYC Compliance Proof*  

$  Required for MICRO Investment upto Rs. 50,000/-. (refer instruction ‘q’)
 Friend in need details In case UTI MF is unable to communicate with me/us at my / our registered address, I / we authorize UTI MF to correspond with the
following person to ascertain my/our updated contact details. (Refer instruction - ‘k’)

Name
F I R S T M I D D L E L a s t

Address:

Relationship with the applicant (optional) Email Mobile

bank particulars OF APPLICANT / minor (Mandatory as per SEBI guidelines) (Please ensure that the cheque complies to the CTS 2010 Standard)
Bank Name Branch

Address MICR Code

City *Pin (this is a 9-digit number next to your cheque number)

Account type (please ) Savings  Current  NRO  NRE IFS Code

(this is a 11-digit number)

Account No.

Investment and payment Details (For “Direct Plan” Please tick here & tick Plan Period / type of insurance cover given below) (Refer instruction - ‘j’ & ‘y’)
(Please ensure that the cheque complies to the CTS 2010 standard)

Target Amount (`) Mode of contribution Age in Yrs Sex

     
Yrly Half Yrly SIP / Micro SIP
Male Female

Investor opting for Systematic Investment Plan (SIP) / Micro SIP should fill in the separate form for the same.

Number of contributions now paid (initial + renewal) = ________________________________ (not applicable for SIP / Micro SIP)

Scheme / Plan Period Insurance Cover (#Default, if not ticked) Amount of Investment (`) DD Charge if any (`) Net Amount Paid (`)

UTI-ULIP 10 Year Plan Declining Term #    Fixed Term

UTI-ULIP 15 Year Plan Declining Term #    Fixed Term

† Cheque/DD/NEFT/RTGSv Ref.No. / Cash Account type Savings Current NRE

Unique Serial No. (For Cash)
(please ) NRO DD issued from abroad
Account No.

Bank & Branch _______________________________________________________________________________________________________________________________

  Please tick if the above payment is made from your Spouse / HUF Bank Account. In case of Spouse, please tick        Husband     Wife     HUF
† Please mention the Application No. on the reverse of the Cheque/DD, NEFT/RTGS advice. Cheque/DD must be drawn in favour of “UTI-ULIP” & crossed “A/c Payee Only”.
v Investment amount shall be ` 2 lacs and above in case of payments through RTGS.
  UTI Smart Form if already registered (Applicable for existing invest)
I have regular and independent income YES NO
I am a resident non-resident Indian. In case I become NRI, I shall inform UTI AMC my address in India to which communications may be sent by UTI AMC.

In case of non-receipt of contribution by the due date, UTI AMC is hereby authorised to redeem units in my folio for payment of premium to the insurance company (Please strike off if the same is not acceptable).
I hereby declare that an aggregate target amount of all my memberships in force including the one being now applicable for does not exceeds ` 15,00,000/-. I realise that in the event of its exceeding ` 15,00,000/- for
any reason whatsoever, the insurance cover on my life, will be restricted to ` 15,00,000/- (` 5,00,000/- for females without regular income).
I am aware that (i) I will be covered under the Personal Accident Insurance to such extent and so long as UTI MF extends the facility irrespective of the aggregate target amount under the Scheme. (ii) The above
insurance cover when in force is in addition to the Life Insurance cover under the Scheme, I declare that in the event of my having taken or taking up a similar accident insurance policy to cover the same risk my claim
shall stand restricted under my own policy and will not be eligible for the cover provided under the Scheme.

Particulars of health. (Applicants who are unable to complete this form of declaration of good health to UTI AMC’s satisfaction, will not be admitted to the plan.)
(A) Am I in sound health: YES NO  (If No, investment under UTI-ULIP is not permissible)

(B) Have I ever suffered from any of the following:  NO YES (If yes, please tick from the following) (If suffering from any of the following ailments, application will be liable for rejection)

Tuberculosis Cancer Paralysis Insanity Any disease of the heart and lungs

Kidney disease Any disease of brain Diabetes Hypertension Any other serious disease

(C) Do I have any physical deformity or handicap: NO YES  If yes, (i) the date of occurrence________________________ (Enclose the Certificate of deformity)

(ii) the extent of deformity_____________________________ (iii) the present condition________________________________________________ (iv) whether gainfully employed YES NO

(D) Declaration of heath: I hereby declare that I am in good health and free from disease, that I did not have any serious illness or major operation for the last five years and no proposal of insurance on my life
to Life Insurance Corporation of India / any other life insurance company has ever been adversely treated. I further declare that to the best of my knowledge the foregoing statements and answers are true and
correct in every particular and the said statements and this declaration shall be the basis of my admission to UTI MF’s UTI-Unit Linked Insurance Plan.
 Health Declaration (To be completed by the Financial Advisor of UTI AMC or by the authorised person^)
The applicant has completed and signed the application in my presence. From his/her appearance and to best of my judgement, I find that he/she is in good health and has a
sound constitution. His/Her date of birth mentioned above is verified by me from __________________________________________________ (Please state nature of proof).
The applicant is known to me personally/has been introduced to me by Shri/Smt./Kum.______________________________________________________________ whose
signature is appended.

--------------------------------------------------------------------------------------------------------
(Signature of witness identifying the applicant) á --------------------------------------------------------------------------------------------------------
(Signature of the authorised person) [mandatory] €
Date: ________________________ Place:___________________ M Date: _____________________ Place:______________________________
A Name of authorised person
Name of witness N
(in block letters)_________________________________________ D (in block letters)____________________________________________________________
A Status: (UTI AMC Financial Advisor, Magistrate, Bank Manager etc.)__________________
Occupation:____________________________________________ T
O Code No. (If UTI AMC Financial Advisor):________________________________________
Address:______________________________________________ R Office Seal (if others):_______________________________________________________
Y
Address:______________________________________________ Address:_________________________________________________________________

Address:______________________________________________ Address:_________________________________________________________________

€ In absence of above the application is liable to be rejected

^UTI AMC BDA/Financial Advisor/Magistrate/Manager of a scheduled bank/JP/Gazetted Officer/Officer in charge of Defence Personnel/Officer of UTI AMC

GENERAL INFORMATION - Please () wherever applicable

STATUS:   Resident Individual   Minor through guardian   NRI  

Occupation:  Business   Student   Agriculture   Self-employed   Professional   Housewife

  Retired   Private Sector Service   Public Sector Service

  Government Service   Forex Dealer   Others (Please specify) ___________________________________________________

Marital Status   Unmarried  Married   Wedding Anniversary D D M M

Category under In my/our individual capacity On behalf of minor as Father/Mother/Lawful guardian

UTI-ULIP (Please fill in the nomination form)

Other Details (MANDATORY)

For Individuals Only

1st Applicant: (A) Gross Annual Income Details Please tick ()

  Below 1 Lac   1-5 lacs   5-10 Lacs   10-25 Lacs   >25 Lacs - 1 Crore   >1 Crore

[OR]

(Net worth should not be older than 1 year)

Net-worth in ` _______________________________________________________________________ as on (date) D D M M Y Y Y Y

(B) Please tick if applicable:   Politically Exposed Person (PEP) Related to a Politically Exposed Person (PEP)
(For definition of PEP refer instruction ‘x’)

(C) Any other information: _____________________________________________________________________________________________

details under fatca (Foreign Tax Compliance Act) and CRS (Common Reporting Standard) (Refer instruction ‘z’)

Information to be provided by the Applicant

Are you a tax resident of any country other than India ?

If No, please tick here :    First Applicant/Guardian

If Yes, please tick here :    First Applicant /Guardian please fill in the Particulars in the prescribed Form for FATCA/CRS and attach it with this Application Form.

 

ACKNOWLEDGEMENT (To be filled in by the Applicant)

UTI-Unit Linked Insurance Plan (UTI-ULIP) Sr. No. 2018/
(UTI-ULIP is eligible for deduction under Section 80C of the Income-Tax Act, 1961)

Received from Mr / Ms

along with Cheque / DD No.$ /

NEFT/RTGS Ref. No./Unique dated
Serial No. (For Cash)

Drawn on (Bank)
Stamp of UTI AMC Office/
for ` (in figures) Authorised Collection Centre
$
Cheques and drafts are subject to realisation.
 NOMINATION DETAILS (Please ) (Person applying on behalf of Minor cannot nominate) (please sign if you do not wish to nominate)

I/We hereby nominate the undermentioned Nominee to receive the amounts to my / our credit in the event of my / our death. I/We also understand that all payments and settlements made to
such Nominee and signature of the Nominee acknowledging receipt thereof, shall be a valid discharge by the AMC / Mutual Fund / Trustee.

Name and Address of Nominee To be furnished in case nominee is a minor

Name Name of the guardian

Date of Birth d d m m y y y y Address of guardian

(in case of nominee is a minor)

Mobile No.

Address

Signature of Nominee / guardian (for minor)

Investors who wish to nominate two or three persons may fill in the separate form prescribed for the same and attach it with this application form.

Sign.
here
Ê I/We do not wish to nominate

Signature of Applicant / Guardian

Declaration and Signature of Applicant/s

l l/We have read and understood the contents of the scheme information documents, statement of additional information and Key information Memoranda, addenda
issued till date and apply to the trustee of UTI Mutual fund as indicated above. I/We agree to abide by the terms and conditions, rules and regulations of the schemes
as on the date of investment. I/We undertake to confirm that this investment has been duly authorised by appropriate authorities in terms of all relevant documents
and procedural requirements. l I/We have not received nor been induced by any rebate or gifts, directly or indirectly in making investments. l the arn holder has
disclosed to me/us all the commissions (in the form of trail commission or any other mode), payable to him for the different competing schemes of various Mutual funds
from amongst which the scheme is being recommended to me/us. l I/We hereby authorize UTI Mf/UTI aMc to share my data furnished in the form to my distributor
and other service providers of the UTI Mf for the purpose of servicing, issue of account statement/consolidated statement of account etc and cross selling of products/
schemes of the UTI Mf. l I/We confirm that we are non-residents of indian nationality/origin and that the funds are remitted from abroad through approved banking
channels or from my/our nre/nro account. I/We undertake to provide further details of source of funds and any such other relevant documents, if called for by UTI
Mutual fund. (applicable to nris.) l i hereby solemnly declare that i am the father/mother/guardian of the minor child in whose name the application is made. the
date of birth stated by me is true and correct. I do not have any documents in support of the date of birth and relationship with minor child. l I/we wish to receive email
and SMS communication from UTI Mutual Fund. l I/We hereby provide my /our consent in accordance with Aadhaar Act, 2016 and regulations made thereunder, for
(i) collecting, storing and usage (ii) validating/authenticating and (ii) updating my/our Aadhaar number(s) in accordance with the Aadhaar Act, 2016 (and regulations
made thereunder) and PMLA. l I/We hereby provide my/our consent for sharing/disclosing of my/our Aadhaar number(s) including demographic information with UTI
MF / UTI AMC and their Registrar and Transfer Agent (RTA) for the purpose of updating the same in my/our folios. (strike out if this declaration is not applicable).

OPTION FOR DESPATCH OF STATEMENT OF ACCOUNT (SoA)

  Through email∞   SoA in Physical Form   At my Overseas address as mentioned above®   To be dispatched to my resident relative’s address in India as mentioned above®
∞  Please send the Account Statement, Abridged Annual Report, Transaction confirmation, communication of change of address, change of bank details etc. through email only at the below email ID.
® Applicable to NRIs

Mobile No. Tel. (R) STD CODE Tel. (O) STD CODE
First
Applicant
Details
*E-mail Alternate E-mail

Sign.
here
Ê

Signature of Applicant / Guardian / POA^^

^^  Power of Attorney (POA) Registration No._________________________(if already registered) (refer instruction ‘aa’)
 
Notes :
1. If the application is incomplete and any other requirement is not fulfilled, the application is liable to be rejected.
2. Consolidated Account Statement (CAS) will be sent within 10 days of the following month of the transaction.
3. Please ensure that all KYC Compliance Proof and PAN details are given, failing which your application will be rejected. PAN not applicable
for Micro SIP.
4. All communication relating to issue of Statement of Account, Change in name, Address or Bank particulars, Nomination, Redemption, Death Claims
etc., may please be addressed to the Registrar :
M/s. Karvy Computershare Private Limited, Unit: UTIMF, Karvy Selenium Tower B, Plot Nos. 31 & 32, Financial District, Nanakramguda,
Serilingampally Mandal, Hyderabad – 500 032.
Board No:  040 - 6716 2222, Fax no  :  040- 6716 1888, Email:[email protected]
ARN-121213 E 189089

`
 UTI-ULIP SIP and Micro SIP INSTRUCTIONS
UTI ULIP SIP / Micro SIP Applications is to be submitted along with the UTI ULIP Application Form
1. Monthly Systematic Investment Plan (MSIP) and Quarterly Systematic insurance cover is payable in case of death less than 6 months from the
Investment Plan (QSIP) are offered under UTI-ULIP. Investors will be commencement of membership. For 6 months and above but less than 1
considered to be under the yearly mode of contribution and premium year the life insurance cover is 50% of the target amount unpaid but not
applicable for yearly payment will be considered. The premium payable due. For example for target amount of `  120,000/- under the 10 year
for a year will be deducted from the first SIP/Micro SIP instalment plan, the yearly instalment due is `  12,000/- and the unitholder has died
received that year. after paying only `  7000/- (7 monthly instalments) the Life Insurance
Cover payable is 50% of `  120,000/- less `  12,000/- i.e. `  54,000/-
2. MSIP under UTI ULIP is open to investors between the age group 12
and not `  56,500/- (50% of `  120000/- less `  7000/-). For 1 year and
years and 48½ years in case of the 10 year plan and between the age
above 100% of the target amount unpaid but not due is payable. For
group 12 years and 42½ years in case of the 15 year plan.
example under the 10 year Plan for a target amount of `  1,20,000/- in
3. QSIP under UTI ULIP is open to investors between the age group 12 years case a unitholder dies after paying 15 instalments (`  15000/-) the life
and 55½ years in the case of 10 year Plan and between the age group of insurance cover payable is `  1,20,000/- less `  24,000/- i.e. `  96,000/-
12 years and 50½ years in case of the 15 year Plan. ).
4. The load applicable under SIP is the same as for regular investments viz. Under Fixed Term Insurance Cover: No life insurance cover is
Purchase load: Nil. Redemption load: 2% if redeemed before maturity. payable in case of death less than 6 months from the commencement
of membership. For 6 months and above but less than 1 year the life
5. Monthly Instalment: The initial investment (to be given by cheque)
insurance cover is 50% of the target amount. For 1 year and above
and SIP instalments should be of uniform amount. The minimum
100% of the target amount is payable.
monthly instalment under SIP is `  500/- and in multiples of `  100/- i.e.
the minimum target amount under the 10 year Plan is `  60,000/- and 7. SIP/Micro SIP Mandate Form should be submitted atleast 1 month before
in multiples of `  12,000/- (Total subscriptions during the term shall be the first instalment date. Such of the Forms that are received within the
`  72,000/-, `  84,000/-, `  96,000/- ...... and so on) and the minimum period of 1 month before the first instalment date, will be considered from
target amount under the 15 year Plan is `  90,000/- and in multiples of the SIP/Micro SIP date of the subsequent month, as per the date opted by
`  18,000/-. (Total subscriptions during the term shall be `  1,08,000/-, the Investor. Currently investment can be made on the 1st, 7th, 15th or
`  1,26,000/-, `  1,44,000 ........ and so on). 25th of a month.
Quarterly Instalment: The initial investment (to be given by cheque) 8. The period of SIP/Micro SIP shall be the plan period chosen by the
and SIP instalments should be of uniform amount. The minimum investor i.e. 10 years or 15 years. For a 10 year SIP/Micro SIP there will
quarterly instalment under SIP is `  1,500/- and in multiples of `  100/- be the initial investment plus 119 instalments for Monthly SIP/Micro SIP
i.e. the minimum target amount under the 10 year Plan is `  60,000/- and 39 installments for Quarterly SIP/Micro SIP. For a 15 year SIP/ Micro
and in multiples of `  4,000/- (Total subscriptions during the terms shall SIP there will be the initial investment plus 179 instalments for Monthly
be `  64,000/-, `  68,000/-, `  72,000 ...... and so on) and the minimum SIP/Micro SIP and 59 instalments for Quarterly SIP/Micro SIP. Post dated
target amount under the 15 year Plan is `  90,000/-, (Total subscriptions cheques will have to be given for a period of atleast 1 year at a time.
during the term shall be `  96,000/- `  1,02,000/-, `  1,08,000/- ......
9. Existing Investor cannot start the SIP/Micro SIP for target amounts already
and so on).
chosen by him. SIP/Micro SIP can be started only for additional target
6. Under Declining Term Insurance Cover: Life insurance cover is amounts. Investors should attach the SIP/Micro SIP Enrolment Form with
to the extent of the unpaid but not due amount of the chosen target the Scheme Application Form. All details about the Investor will be as
amount as applicable for the yearly instalment payment. No life provided by the Investor in the Scheme Application Form.

Plan/Regular Plan/Retail

UTI-Bluechip Flexi Cap Fund

UTI-Long Term Equity Fund (Tax Saving)

Scheme
Scheme
Scheme