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m 4. 300 (& 2002) 1
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Rirrpal: 5,000 16-10 170 GSM Paper IF. No. 300 (Rev:2W2)
-22~ Life kumnce (forporntiom of Tndip .
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Nadiad Divisional Offlce
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Inward Number Branch Trwiihhq
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( + I = I % ~ ~ W1956mm) af%id u. f3.a.u.
(~stablishedby the Life lnsurance Corporation Act. 1956) Agent's Code Number DO Code
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PROPOSAL FOR INSURANCE ON OWN LIFE
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Proposal No.
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Date
(Not to be used for insurance on other lives and the Lives of Mlnors)
( ~ 9 s t ~ ~ ~ m 1 m ~ ~ ~ 1 h , ~ ~ ~ h-mdM*l)
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(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)
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Full Name (Surname first) and Address to which commun~cationsare to be sent Object of Insurance
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Ti.(yFL8.3.q z d ; Wl) (gi) (*)
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Place of Birth
Nationality
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Sex'
lele No. (with STD Code (R)
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Vfl J E-mail address :
(i)
(0)
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Nature of Age-Proof Submitted
(iii) w.q.#[Link]
Bank Account Details : (i) (SavingICurrent) (ii) Alc. No.
(iii) MlCR Code (iv) Name &Address of your Bank
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Residential address, if different from above
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Father's Full Name (Surname first) ,
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2kTf T (-3~) em /Age 3TFd W4 / Relationshipto yourself.
2A Nominee's Full IVame (Surname lirst) and Address
24 ~ ~ * ~ ~ l ~ f i g m ~ ~/ Age ~TfR T d;[Link]
@ Relatio~nsipto Nominee,
2B If nominee is a Minor, Appointee's Full name and address
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Signature of Appointee as token of consent
Term Rider Critical ;PII f$T?Vl T T Tf$lT, ?Ti. Til. 4.
Sum Sum illnessSum *wfl$? ~f;lmM Amount BOC No.
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Proposed Proposed Proposed
, 1 Accident ft&j mfi 3 q$ $ deposited
3A Plan &Term (if required) (if benefit required ? If Policy is to be dated Rs.
back, indicate date.
I I I I I
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~n 33 ~ T W ~ F .
Paying Authority Code Dept, IVo. Badge or S. R. No.
Mode (Yearly, Half-Yly, Ouaneriy1
Monthly or under SSS) Single
3~~~rnrn~.siffsss3~frnm~~+?
3B Is critical illness or premium waiver benefit (PWB) require ?
4T *-
4A Present Occupation
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Exact Nature of Duties
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4B Name of Present employer Length of Service with Him
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Education Annual Income Rs. Sources of Income $?<$I ~~3.4.
Qualification Are you an Income Tax I
Assessee ? If yes PAN
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6 J T ~~l~mrghd;~~
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~ f 4? p r 51 :I If your are employed in the Armed Forces, Please state :
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~ ( h )f ~ - m m ~ w % M Q m I c r f t w d ; mm*M
II
Rank Date of Last medical i
8.
s~mmm Examination
3Tq~me4M m
Defence wing to
therein Medical category 4
. which you belong after examination ??**dm?
'
Were you ever below ,
A-1 ,.Category? If so, when ?
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If your life also proposed for another assurance or an application for Revival of a policy on your life is under consideration in any
\office of the Corporation or any other insurer if yes, give details. I
q. **~ur~frn*firmTrmf?
3.~ q l i i r 4 ~ ~ . y ; s ~ * rnTrm~?
Has a proposal (or an application for Rev~valof a Pol~cy)on your l~fe Answer If 'Yes',
made to any office of the Corporation or any other insurer ever been 'Yes' or 'No' give Details
(a) Wlthdrawn, Deferred, Dropped or Declined 7
(b) Accepted w~thExtra Premium or hen 7
(c) Accepted on terms otherwise than those proposed 9 I
~ ( 3 )m d f % $ w ~ & ~ ~ # 4 m ~ + ~ m ~ % ?
8(B) Have you durlng the past one year returned any policy of the Corporation as the same was not acceptable to you ? if so, givc
details
9 s m i t u . r i t m ~ w * m m ( m ? m * . r r d * ~ ~ d ~ d )
Please glve details of your previous insurance : (Including pollcies surrenderedllapsed dur~nglast 3 years)
Insurance %V7 Term Crdlcal Amount ji[ij # qq q ql &q 3
Pol. No
CorrpanEs
from where
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Sum Assurance
~ s s u - R~der
illness
Rider
of
Acudent
3irT-i rnr~pm $m
Ln mm
the prevlous Table ured Sum Sum BeneM Year flCm*v ~8 f$;saq
poIlcy/Pol~~aes Terms on main Assured Assured taken of %EM Medical Whether qn&q w
have been issue or In
plan Whether 11 not. give
purchased wdh non- for fulldue date ol
address ( ~ f as proposed medical
last prem~ue
prevlous Pol~aes at ord~nary Assu~ed paid or
are from LIC of rates date of
ndla, glve name surrender
of BranchIDO)
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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.
