Form No.300
(BN) 98
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|
LIFE
INSURANCE CORPORATION OF INDIA (Established
by the LIC Act 1956) |
Branch
Office: ______________________________ Proposal
No:______________
Agents
Name: ____________________________
License No
Date. Of Expiry
. Agents & DO Code.
NOTE:
This form
has to be filled in by the proposer in his/her own handwriting. If he/she cannot write in the language
of this form or he/she is illiterate, the proposal form can be filled in by the
Agent/Third party as per normal rules.
1
a)
Name in full (IN BLOCK LETTERS):
Mr. /Mrs./Miss
b)
Short Name
c)
Address for Correspondence
d)
Nationality
e)
Are you resident in India?
f)
Fathers Name in full
2
a)
Table/Term
.. b)
Sum Assured
..
c)
Amount of deposit
..
d) Date of Birth
.
e)
Age Proof
..
3
a)
Nominee under Section 39 of the Insurance Act, 1938, to whom policy
moneys
Will be
payable in the event of death.
Nominees
full name:
(IN BLOCK LETTERS)
Age
..Relation to yourself
.
Full
Address:
.
.
.
b)
Appointees
Name with signature to whom the policy money is payable in the event of the
claim arising during the minority of the nominee.
Full Name of
the Appointee:
(IN BLOCK LETTERS)
Full
Address
.
Signature of
the Appointee
Relationship
to the Nominee
.
Age of
Appointee
.
:
2:
4
(a)
Present Occupation
...
(b)
Nature of duties
.
(c)
Annual Income
.
(d)
Total Sum
Assured under
Previous
policies under
Table
132
5
(a) Has a
proposal on your life or an
application for revival of a policy
On your life made to this or any
Other Office of the Corporation ever
Been
..
(i)
Declined
:
Yes/No
..
(ii)
Accepted
with extra:________________________________________
(iii)
If yes,
State the
highest extra
Imposed
(excluding age extra)
:
.
(b)
Is any
proposal/application for
revival pending with any office of
the Corporation, if so, give the details :
..
6
Your exact Height without shoes (in cms)
:
.
Your exact Weight (in Kgs.)
:
.
Answer Yes or No
(If NO give details)
7
Are you at present in good health?
:
8
Have you
ever been admitted to a
Hospital/Nursing
Home for taking
Treatment
for a week or more during
The last 3
years? (If Yes give details)
:
9
Have you any
physical deformity?
If yes, give
details and total
Sum Assured
in force under all previous
Policies
taken during last five
calendar
years including current year.
:
.
10
To be
answered by female proposer only
a)
Total sum
assured in force under all
Previous
Policies taken during last
5 calendar
years including current
year
:
.
b)
If you are
married
(i)
Are you pregnant now?
:
.
(ii)
Have you had
any pregnancy
related
problems at any time :
.
: 3
:
DECLARATION BY THE
PROPOSER
I
.. do hereby
Declare that
the foregoing statements and answers have been given by me after fully
understanding questions and the same are true, and complete in every
particular. I agree that if any
untrue averment by contained therein the said contract shall be absolutely null
and void and all moneys which have been paid in respect thereof shall stand
forfeited in part or full to the Corporation.
Dated at
on the
. day
.. 200
..
Name of
witness
Signature of
witness
.
Occupation
..
Address
Signature or thumb impression
of the person whose life is
proposed to be assured
If the
answers to the questions in this form are given in vernacular and the proposer
signs in vernacular then the proposer signs in vernacular then the proposer
should declare in his/her own handwriting above his/her own signature that all
questions were explained to him/her and that his/her replies were given after
fully and properly understanding the same.
OR
In case the
proposer is ILLITERATE , the
thumb impression of the proposer 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/her.
I hereby declare that I have fully explained the
Above questions to the proposer in
.
(language)
and I have truthfully recorded the answers and explained to the proposer the answers to the questions dictated by
the proposer and that the proposer has affixed his/her thumb impression to the
proposal form after duly understanding the contents
thereof.
Address of
the Declarant
.
(Signature of the Declarant)
NOTE: In case of dispute in
respect of interpretation
of terms the English version shall stand valid.