Life Insurance Corporation of  India

F.No.440(Rev-June 2000)/44-45

(Established by the Life Insurance Corpn. Act, 1956) Office use only
  Date of Receipt
  Inward No. Initials

PROPOSAL FOR AN ANNUITY

 Is Licence in Force Initials
P&GS Unit Branch Office
Proposal No Details of Club Membership Proposal No
Agent's Name
Licence No. Date of Expiry
Agent's Code No.    
(All answers to be filled in legibly. Answers must be given in words. Strokes of Pen or dots or dashes will not be accepted as answers)
1.(a) Name in full of the person proposing to purchase the Annuity
(b) Present Address
 
 
Pin Code
Telephone No.
(c) Permanent Address
 
 
Pin Code
Telephone No.
(d) Age
(f) i) Age Last Birthday
ii) Date of Birth
iii) Nature of Age proof being furnished with the proposal
2.(a) Name in full of the Annuitant, i.e., the person on whose life, annuity payments depend
(b) Present Address
 
 
Pin Code
Telephone No.
(c) Permanent Address
 
 
Pin Code
Telephone No.
(d) Sex
(e) Nationality
(f) i) Age Last Birthday
ii) Date of Birth
iii) What proof of age is being furnished with the proposal
3. Description of the Annuity :  
(a) Annuity Table Number
(b) Whether Immediate or Deferred  
(c) Please indicate the type of annuity
i) Annuity during the lifetime of the Annuitant (without any guaranteed period)? or  
ii) (a) Annuity for a guaranteed term of years and during subsequent lifetime of the Annuitant?  
(b)  If so, state the guaranteed term in years, or
iii) Annuity during the lifetime of the annuitant with return of cash option/Purchase Price on death of the annuitant, or  
iv) Increasing Immediate Life Annuity  
(d) Whether annuity installments are to be paid yearly, half-yearly, quarterly or monthly
(e) Amount of Annuity Installment, or, initial installment amount in case of increasing annuity
(f) Dates on which Annuity installments are to be paid
(g) Purchase Price
(h) If a Deferred Annuity is desired, please state:
i) the period after which the Annuity is to vest
ii) Whether premiums are to be paid in  
(a) yearly, half-yearly, quarterly or monthly installments or single premium
(b) amount of installment/single premium
4.(a) If proposer and annuitant are the same: Nominee to whom benefits, if any, are to be paid under the policy in case of death of the annuitant
i) Name
ii) Relationship to the annuitant
iii) Address
 
 
Pin Code
Telephone No.
(b) If the proposer and annuitant are different: Nominee to whom benefits, if any, are to be paid under the policy in case of death of the annuitant while annuity is in payment
i) Name
ii) Relationship to the annuitant
iii) Address
 
 
Pin Code
Telephone No.
5. Have any Deferred Annuity policies taken by the proponent, been surrendered during the preceding three years? If so, please furnish the following details:
Name of the Branch Office /P&GS Unit Policy No. Purchase Price/ Cash Option Plan No. Year & month of Issue of Policy Year and month of surrender

Declaration

I/We , and do hereby declare that the foregoing statements and answers are true in every particular and do agree and declare that these statements and this declaration shall be the basis of the contract of annuity between me/us and the Life Insurance Corporation of India and that if any untrue averment be contained therein, the said contract shall absolutely be null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.
Dated at on this day of 2000
Name of Witness
Signature of Witness: 
Occupation

  Signature or Thumb Impression of the Proposer

Address:   

(the person proposing to purchase the annuity)

                  
Occupation  
Name of Witness  
Signature of Witness:   
Address:  
             

Signature of the Annuitant

   
If the answers to the questions in this form are given in vernacular, or if the answers are given in ENGLISH but the Proposer signs in vernacular then the proposer should declare in his own  handwriting above his own signature that all questions were explained to him and that his replies were given after fully and properly understanding the same.
In case, the Proposer is illiterate:  
1) This declaration should be made by the person filling in the form. I hereby declare that I have fully explained the above questions to the proposer and I have truthfully recorded the answers given by the Proposer.
Name  
Address of the Declarant

Signature

 
2) The thumb impression of the Proposer 
should be attested by a person of 
standing whose identity can be easily 
established but unconnected with the 
Corporation and this declaration should 
Be made by him.		 2) I hereby declare that I have explained the contents of the proposal form to the Proposer in language and that I have read out to the proposer the answers to the questions dictated by the proposer and that the proposer has affixed his thumb impression to the proposal form after fully understanding the contents thereof.   
  Name and    
  Address of     
  the Declarant    
     

Signature

N.B. Rebate of premium 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 rebate shall be an offence under section 41 of the Insurance Act,1938.

 

 
Specimen Signature of the Annuitant

Agent's Report:

1. (a) Have you canvassed the proposal yourself. 
If not, state reasons therefore and who has canvassed the proposal
  (b) Give marks of identification
2. (a) What is the approximate age of the Annuitant in your opinion.
  (b) Do you consider the income of the Proponent sufficient to take this Policy?
3. Do you recommend the acceptance of the Proposal
I hereby declare that the foregoing statements are true and correct to the best of my knowledge and belief.
Dated at

on this day of 2000.

Signature of the Agent