LIFE INSURANCE CORPORATION OF INDIA

F.No:300 (Rev-98)

LIFE INSURANCE CORPORATION OF INDIA
(Established by the Life Insurance Corporation
Act, 1956)

PROPOSAL FOR INSURANCE ON OWN LIFE
(Not to be used for Insurance on the Lives of Minors)
DIVISIONAL OFFICE:

(All answers to be filled in legibly; Answers must be
given in words, Stroke of the pen or dots or dashes
will not be accepted as replies)

Proposal/ Policy No.

Branch

Agent Code / DO Code

Inward No.

Date

Is licence of Agent in force?

Initials

1
Full Name (Surname First) and Address to		Object of Insurance
which communications are to be sent		Place of Birth
.		Nationality
Pin Code		Sex
Telephone No.		.	.
Permanent Residential address, if different		Nature of Age-proof submitted
from above		Age (Nearer Birthday)
.		Date of Birth
Pin Code		.	.
Telephone No.		.	.
Short Name	Father's Full Name (Surname First)

2
(a) Nominee's Full Name (Surname First) and Address	Age		Relationship to yourself
	.	.	.	.
	.	.	.	.
	.	.	.	.
(b) If Nominee is a Minor, Appointee's Full Name, Address, Relationship to Nominee	Age		.	.
	.	.	.	.
	.	.	.	.
	.	.	.	.
.	.	Signature of Appointee as token of consent

3
Plan & Term	Sum Proposed (Rs.)		Is Accident Benefit required	If Policy is to be dated back, indicate date	Amount deposited Rs.		BOC No.

Mode		Paying Authority Code		Dept. No.		Badge or S.R.No.

FOR OFFICE USE ONLY

Rid	Policy Number	Risk Date	Plan	Term	PPT	Sum Assured

Mode	Inst. Premium	No. of Dues	Next Due	DAB Prem	Extra Prem	Age	Age Proof Code	Sex Code	M/NMG/NMS

R/U F/S

Acceptance Code

Imp Indn

EMR Code

Reins

Income Code

Occ Code

Bill Type

Title

Rein.

Dist.

Taluk

Vilg.

Final Underwriting Decision with Underwriter's Full Signature

Date of Completion

Date of last Payment

Date of Maturity

N.B. Rebate of premiums shall be allowed only in accordance with the details given in the prospectus or table of premium rates or, as the case may be, the relevant document, and that an offer or acceptance of any other rebates shall be an offence under Section 41 of the Insurance Act, 1938.

4(a)
Present Occupation	Exact Nature of Duties

(b) Name of present employer	Length of service with him

5

Educational Qualification

Annual Income Rs.

Source of Income

Are you an Income-Tax Assessee?

6 If you are employed in the Armed Forces, please state :

Wing to which you belong

Rank therein

Date of last medical examination

Medical category after medical examination

Were you ever below A-1 category? If so, when?

7. Is your life now being proposed for another assurance or an application for revival of a policy on your life under consideration in any office of the corporation? If yes, give details

8
Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation ever been :
(a) withdrawn, deferred, dropped or declined?
(b) Accepted with extra premium or lien?
(c) Accepted on terms otherwise than those proposed?
9

Please give details of your previous insurance:(including Policies Surrendered / lapsed during last 3 years)
Policy No.	Office of the Corporation	Sum assured	Table & Term	Mode (Yly /Hly /qly /Mly SSS)	Year of Issue MM/YY	Whether Accepted at ordinary rates	With accident benefit	Medical or non- medical	Whether in force for full Sum Assured	If not give due date of lost premium date (MM/YY)








N.B.: Corporation does not entertain any fresh proposal for insurance where a Policy has lapsed or has been converted into paid-up policy within the last 3 years.

Family History:
	Present Age	State of Health	If dead, age & year of death	Cause of death
Father
Mother
Brothers: Living No. Dead No.
Sisters: Living No. Dead No.
Wife/Husband
Children: Living No. Dead No.

11 Personal History:
(a) During the last five years did you consult a Medical Practitioner for any ailment requiring treatment for more than a week?
b) Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation?
(c) Have you remained absent from place of work on grounds of health during the last five years?
(d) Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous system?
(e) Are you suffering or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Low Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?
(f) Do you have any bodily defect or deformity?
(g) Did you ever have any accident or injury?
(h) Do you use or have you ever used:	Reply
i) Alcoholic drinks
ii) Narcotics
iii) Any other Drugs
iv) Tobacco in any form
(i) What has been your usual state of health?
(j) Have you ever received or at present ailing/ undergoing Medical advice, treatment or tests in connection with Hepatitis 'B' or an AIDS-related condition?

12
In Non-Medical cases, please state exact Height in Cms., and Weight in Kgs. (without shoes):	Height		Weight

13: Additional Questions in the case of Female Lives

(a) Are you pregnant now?	Date of last delivery	Have you had any abortion or miscarriage or Caesarian Section? If so, give details.	Date of last Menstruation
	mm/dd/yy		mm/dd/yy

(b) Husband's Full Name	His occupation	His Annual Income (Rs.)

(c) Details of Husband's insurance
Policy Number	Office of Corporation	Sum Assured	Table & Term	Present status of the Policy

DECLARATION BY THE PROPOSER
I, (name of the proposer) do hereby declare that the statements and answers under headings 1 to 7 of the proposal form have been given by me after fully understanding the questions and the same are true and complete in every particular and agree and declare that these statements and this declaration along with the statements made by the life to be assured under headings 8 to 25 of the proposal form and declaration relative thereto shall be the basis of the contract of assurance between me and the Life Insurance Corporation of India and that if any untrue averment be contained therein the said contract shall be absolutely null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.
Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital and / or employer from divulging any knowledge or information about me concerning my health or employment on the grounds of secrecy, I, my heirs, executors, administrators and assignees or any other person or persons, having interest of any kind whatsoever in the policy contract issued to me, hereby agree that such authority, having such acknowledge or information, shall at any time be at liberty to divulge any such knowledge or information, to the Corporation.
And I further declare that if after the date of submission of the Proposal but before the issue of First Premium Receipt (I) any change in the occupation of the life to be assured or any adverse circumstances connected with the financial position or general health of the life to be assured or that of any member of his family occurs or (II) a proposal for assurance or an application for revival of a policy on the life of the life to be assured made to any office of the Corporation has been withdrawn or dropped, deferred, or declined or accepted with an increased premium or subject to a lien or on terms other than as proposed, I shall forthwith intimate the same to the Corporation in writing to reconsider the terms of acceptance. Any omission on my part to do so shall render this Assurance invalid and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.
Dated at on the day of , 2000

		Signature of witness
Name
Occupation
Address


		Signature or thumb impression of the person whose life is proposed to be assured
If in this form the answers to the questions and/or signature(s) of the Proposer/Life to be Assured are/is in Hindi or any other Indian Language then proposer/Life to be Assured should declare in his own handwriting above his own signature(s) that all questions were explained to him and that his replies were given after fully and properly understanding the same.
1. This declaration should be made by the person filling the form:
Declarant's Name
Address

I hereby declare that I have fully explained the above questions to the proposer/Life to be assured and I have truthfully recorded the answers given by the proposer/ Life to be Assured

		Signature
2. IN CASE THE PROPOSER IS ILLITERATE: The thumb impression of the proposer/Life to be Assured should be attested by a person of standing whose identity can easily be established but unconnected with the Corporation and this declaration should be made by him.

Declarant's Name
Address

I hereby declare that I have explained the contents of the proposal form to the proposer/life to be Assured in language and that I have read out to the Proposer/Life to be Assured the answers to the questions dictated by the Proposer/ Life to be Assured and that Proposer/Life to be Assured has affixed his thumb impression on the proposal form after fully understanding the contents thereof.

		Signature

FOR MEDICAL CASES ONLY
	I certify that the proposer has signed in my presence after admitting that all the answers to Question Nos. 10 onwards of this form have been correctly recorded.

Signature or thumb impression of the Life Proposed	Signature of the Medical Examiner
N.B: Signature or thumb impression should be affixed in presence of Medical Examiner.