Proposal Form

Plan Details

Plan Name Plan No

LIC's Jeevan 745
Umang

Proposal Date * UIN

20-02-2025 512N312V03
Agency Code Supervisor Code Branch Code
0950562A 9999999 62A

Access Id Email Id Mobile No.

2452594727 sharathgowda663@[Link] 9164775311
I hereby confirm that the mobile number provided by me, is registered in my own name. By ticking this box, I
hereby authorize Life Insurance Corporation of India to verify the above information and call me back even if I
am registered in the Do not call List of TRAI

* Date of Proposal - Pertains to date when customer verified the proposal. Proposal number is
allotted only after receipt of the full proposal-deposit amount by LIC

Details of plan proposed

Term & PPT Sum Assured Installment Premium GST

71 - 20 ₹ 10,00,000 ₹ 5,118 ₹ 690
Total Amount Mode of Payment Date of
₹ 16,044 Monthly Commencement **
20-02-2025
AB/ADDB Req AB/ADDB Sum Assured T.R. Sum Proposed
AB REQUIRED ₹ 30,00,000 ₹ 10,00,000
Applicable to Police Personnel if LIC's Accident Benefit Rider / LIC's Accidental Death And Disability
Benefit Rider is opted for :
(i). Whether you are engaged in police duty in any police organization other than Yes No
paramilitary force?
If "Yes", (ii). Whether you wish to avail the AB/AD& DB rider while on police duty? Yes No

** Date of Commencement - This date is tentative Date of Commencement , subject to change

based on date of payment and underwriting.

Personal details of the life to be insured

Name
Sharath P
Father's Name Mother's Name
PARAMESHWARAPPA G R LATHA H C

Gender
Male Female Third Gender
Martial Status Date of birth ABHA number
Single 16-03-1996

Age (in years) Residential Status

29 Years Resident Indian
Do you wish to avail the physical policy document? Yes No

please give EIA no. (e-Insurance Account) if available

Employer-Employee Scheme/KMI/HUF

Whether proposal is under Employer-Employee

No
Scheme/KMI/HUF ?
 Communication details of the life to be insured

Present Address for communication

Address Line 1 Address Line 2
SHARATH P S/O PARAMESHWARAPPA G GAVIRANGAPURA VILLAGE,
R SRIRAMPURA POST
Address Line 3 City District
HOSADURGA TQ HOSADURGA CHITRADURGA
State Country Pin Code
KARNATAKA INDIA 577542
Permanent Residential Address
Address Line 1 Address Line 2
S O Parameshwarappa G R, , , gavirangapura, , Gavirangapura,
Address Line 3 City District
Chitradurga, Karnataka gavirangapura Chitradurga

State Country Pin Code

Karnataka India 577542

KYC Particulars

Are you an It Assessee Yes No

PAN Proof of Identity Age proof submitted

JZDPS9566L ekyc ekyc

If Registered under GST Yes No

Occupation Details

Present Occupation Exact Nature of Name of the present Length of service

duties employer
Service (Listed Service 1 Years
Companies/Institutions) 2 Months
Annual income source of income Education Purpose of
Qualification insurance
₹ 4,00,000 Employed Post Graduate Risk Coverage
(Salary) or Graduate with savings
Are you employed in the Armed Forces Yes No
 Other Personal Details of the life to be insured

Is your occupation associated with any specific hazard or do you take part in hazardous Yes No
activities or have hobbies that could be dangerous in any way?
Are you Politically Exposed Person (PEP) OR are you a family member or close relative of Yes No
PEP ? (As per RBI guidelines PEPs are the individuals who are or have entrusted with
prominent public functions in a foreign country.)
Have you ever been or are currently being investigated, charge sheeted, prosecuted or Yes No
convicted or having pending charges in respect of any criminal/civil offences in any court
of law in India or abroad ?

Lifestyle Details of the life to be insured

Do you smoke / Yes/No If YES, Quantity If STOPPED, Since

consume or have you consumed and how may months
ever smoked / Duration
consumed the
following

Alcoholic drinks Yes No

Narcotics Yes No

Any other drugs Yes No

Do you smoke/consume Yes No

or have you
smoked/consumed
tobacco in any form (
cigars, cigarettes,
beedis, pan masala etc)
in the past 60 months.
(in sticks /packets/
sachets/gms per day)
 Details of previous policies held / proposals applied of the life to be
insured

a) Is your life now being proposed for another assurance or an application for revival of a Yes No
policy on your life or any other proposal under consideration in any office of Life
Insurance Corporation of India or to any other insurer?
b) Whether proposed simultaneously on the life of spouse and children ? Yes No

Has a proposal ( or an application for revival of a policy) on your life made to any office of the
Corporation or to any other Insurer ever been Accepted with extra or modified terms, Withdrawn,
Deferred, Dropped or Declined?, if yes give proposal number& branch / policy number / Name of
Insurer Yes No

Have you during the past one year returned any policy of the Corporation as the same was not
acceptable to you?, if yes give policy number. Yes No

I hereby declare that I do not have any existing policies in-force or lapsed policies with LIC.

I hereby declare that I do not have any existing policies in force or lapsed policies with other Insurers.
 Medical details of the life to be insured

Are you suffering from or have you ever suffered or undergone investigation in the past or have
you been advised to undergo investigation or treatment for the following ailments
1. Lungs/ Respiratory Disease / Persistent cough, asthma, bronchitis, pneumonia, Yes No
Tuberculosis/, pleurisy / spitting of blood/Covid 19etc
2. Peptic ulcer/colitis, jaundice,Hepatitis, anaemia, piles, dysentery, or any other disease Yes No
of the stomach, liver, spleen, gall bladder or pancreas/ digestive disorder
[Link], Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, Yes No
any disease of the heart or arteries?
4. Endocrine disorders such as Diabetes, Goitre, Thyroid etc or have you ever passed Yes No
sugar, albumin, pus or blood in urine
5. Any disease of kidney /prostate or urinary system? Yes No

6. Bone / Joint/ Spine Disease/ Arthritis / varicose veins /any bodily defect or deformity Yes No

7. Any disease of ear, nose, throat or eyes, including defective sight or hearing and Yes No
discharge from the ears
8. Cancer/leukemia/lymphoma/ tumour / cyst/ Any other growth / lumps/ blood disorder Yes No
/enlarged glands
[Link]/epilepsy/ insanity/ tremors, numbness, double vision, dizzy or fainting spells/ Yes No
head Injury / insomnia/ nervous breakdown / Mental Disorder (Depression/ Anxiety, etc.).
/ any other disease of the brain or the nervous system
10. Chronic infections- Skin Disease/ skin eruption/ Leprosy / ,filariasis, gonorrhoea, Yes No
syphilis or any other venereal disease or AIDS&HIV related condition
11. Hernia/hydrocele, varicocele, fistula Yes No

12. Any other disease ? Yes No

 Medical History of the life to be insured

Please state exact height and weight ( without shoes)

Height (in cms) Weight (in Kgs)
168 60

During the last five years did you consult a Medical Practitioner for any Yes No
ailment requiring treatment for more than a week ?
Have you ever been admitted to any hospital or nursing home for general Yes No
check up, observation, treatment or operation?
Have you remained absent from place of work on grounds of health during the Yes No
last 5 years ?
 Family History

(Please mention specifically if suffering from or died of heart disease, stroke, high blood pressure,
diabetes mellitus, cancer, kidney disease or any hereditary disorders, Insanity, or any contagious
diseases such as tuberculosis ,hepatitis, AIDS / HIV etc)

Relationship Living/Dead Present age State of Age of Death Cause of

Health Death

Father Living 56 Good NA NA

Mother Living 49 Good NA NA

Sister Living 25 Good NA NA

 Bank details of the life to be insured

Your bank account type Savings Current

Account Number IFSC Code Bank Name

50100332342662 HDFC0000549 HDFC BANK

Nach Details
Your bank account type Savings Current

Account Number IFSC Code Bank Name

50100332342662 HDFC0000549 HDFC BANK

Settlement Option

Do you Wish to avail Option for Death Benefit in installments Yes No

Nomination Details

Particulars of Nomination

SI No. name of Age Relationship Address of

the to the life Nominee Share(%)
Nominee assured
1 LATHA H C 49 Mother ,,,, 100

Mobile Email Bank Name Account

IFSC Code
Number No
 Summary of Section 45 of Insurance Laws (Amendment) Act 2015

(1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three
years from the date of the policy, i.e., from the date of issuance of the policy or the date of commencement of
risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
(2) A policy of life insurance may be called in question at any time within three years from the date of issuance
of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to
the policy, whichever is later, on the ground of fraud : Provided that the insurer shall have to communicate in
writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and the
materials on which such decision is based.
Explanation I
For the purpose of this sub section, the expression "fraud" means any of the following acts committed by the
insured or by his agent, with the intent to deceive the insurer or to induce the insurer to issue a life insurance
policy :
(a) The suggestion, as a fact of that which is not true and which the insured does not believe to be true.
(b) The active concealment of a fact by the insured having knowledge or belief of the fact.
(c) Any other act fitted to deceive.
(d) Any such act or omission as the law specially declares to be fraudulent.
Explanation II
Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless the
circumstances of the case are such that regard being had to them, it is the duty of the insured or his agent,
keeping silence to speak, or unless his silence is, in itself, equivalent to speak
Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the
ground of fraud if the insured can prove that the mis-statement of or suppression of a material fact was true to
the best of his knowledge and belief or that there was no deliberate intension to suppress the fact or that such
mis​statement of or suppression of a material fact are within the knowledge of the insurer: Provided that in case
of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
Explanation:
A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the formation
of the contract, to be agent of the insurer.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance
of the policy or the sommencement of risk or the date of revival of the policy or the date of the rider to the
policy, whichever is later, on the ground that any statement of or suppression of a fact material to the
expectancy of the life of the insured was incorrectly made in the proposal or other document on the basis of
which the policy was issued or revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or
nominees or assignees of the insured the grounds and materials on which such decision to repudiate the policy
of life insurance is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a
material fact, and not on ground of fraud, the premiums collected on the policy till the date of repudiation shall
be paid to the insured or the legal representatives or nominees or assignees of the insured within a period of
ninety days from the date of such repudiation.
Explanation:
For the purposes of this sub-section, the mis-statement of or suppression of fact shall not be considered
material unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show
that had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to
do so, and no policy shall be deemed to be called in question merely because the terms of the policy are
adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.

Summary of Section 41 of Insurance Laws (Amendment) Act 2015

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out
or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate
of the whole or part of the commission payable or any other rebate of the premium shown on the policy, nor
shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be
allowed in accordance with the published prospectuses or tables of the insurer.
Signature of the life to be
Assured
 Declaration of the life to be insured

I Sharath P the person whose life is herein being proposed to be assured, do hereby declare that the foregoing
statements and answers have been given by me after fully understanding the questions and the same are true
and complete in every particular and that I have not withheld any information and I do hereby agree and
declare that these statements and this declaration 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 dealt with as per provisions of Section 45 of the Insurance Act,1938 as amended from time to
time. Not-withstanding the provision of any law, usage, custom or convention for the time being in force
prohibiting any doctor, hospital ,diagnostic center and/or employer, reinsurer/ credit bureau from divulging any
knowledge or information about me concerning my health or employment , occupation, insurance , financial
etc. on the grounds ofprivacy, 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 knowledge or information, shall at any time be at liberty to divulge any such knowledge
or information to the Corporation, and the Corporation to divulge the same to any Authorised Organisation /
Institution / Agency / and Governmental / Regulatory Authority for the sole purpose of underwriting /
investigation / risk mitigation / fraud control and/or claim settlement. And I further agree that if after the date of
submission of the proposal but before the issue of First Premium Receipt (i) any change in my occupation or any
adverse circumstances connected with my financial position or the general health of myself or that of any
members of my family occurs or (ii) if a proposal for assurance or an application for revival of a policy on my
life made to any office of the Corporation is withdrawn or dropped, deferred or accepted at an increased
premium or on terms other than as proposed, I shall forthwith intimate the same to the Corporation in writing to
reconsider the terms of acceptance of assurance. Any omission on my part to do so shall render this contract to
be dealt with as per provisions of Section 45 of the Insurance Act, 1938 as amended from time to time. I am
aware that if the information on my Tax Residency is found to be false or untrue or misleading or
misrepresenting, I may be held liable for it. I also undertake to inform the Corporation of any change in my Tax
Residency status. I undertake to inform the Corporation immediately of any changes in KYC documents such as
residence. I also give my consent to obtain and share my data from / with Central KYC Registry respectively and
to receive phone calls , SMS/ E mail from Central KYC registry in this regard. I understand that the Corporation
reserves the right to accept /Postpone/ drop/ decline or offer alternate terms on this proposal for life insurance. I
hereby give my consent to receive phone calls, SMS/whatsapp messages, E mail on the above mentioned
registered number(s)/ E mail address from / on behalf of the Corporation with respect to my life insurance
policy/regarding servicing of insurance policies/ notifying about the status of Claim I also understand that the
premium and benefits under the policy are subject to taxes / duties/ charges in accordance with the laws as
applicable from time to time.
Signature of the Life
to be insured

Name Address Pin Code

Sharath P SHARATH P S/O PARAMESHWARAPPA G 577542
R GAVIRANGAPURA VILLAGE,
SRIRAMPURA POST CHITRADURGA
KARNATAKA
 Suitability Analysis

Proposer Full Name Date of Birth

Sharath P 16-03-1996

Age Maritial Status Occupation

29 Years Single Service (Listed Companies/Institutions)

Address
SHARATH P S/O PARAMESHWARAPPA G R GAVIRANGAPURA VILLAGE, SRIRAMPURA
POST HOSADURGA 577542

2. What is proposer'yearly income from: (if life assured is different from the proposer)
Employment Businees / Profession Other Sources H.U.F. if any

Income of life to be
assured

3. Whether income proof submitted? (if Yes, give details below)

Nature of document Is he/she Income tax Is yes, please provide Income Tax Bracket
for income verification Assessee PAN
Yes JZDPS9566L

4. Previous Policy Details (as per proposal form)

5. Family History (as per proposal form)
Spouse Details
Name Occupation Annual Income
NA NA NA

6. Need Analysis
Total Annual Income
₹ 4,00,000

Outstanding Liablities
Secured Loans Non-Secured Loans

based on his age and income, the maximum insurance that can be granted is:
Age Group Multiple of Avg. Maximum allowable
Annual Income Insurance

7.
Object of Insurance How would you like to pay your premiums
Risk Coverage with savings Monthly

Risk Profile Time frame for this invesement

Conservative to Moderate
8. Categorization of plans in relation to object of Insurance
Category Risk Profile Plan Name
Conservative to Conservative to LIC's Jeevan Umang
Moderate Moderate
9. Product Chosen
Plan No Plan Name Term Sum Assured
745 LIC's Jeevan Umang 71 ₹
10,00,000

Mode Premium
Monthly ₹ 5,118

a) if ULIP is proposed:
1st Year 2nd Year 3rd Year onwards Life cover
charges

Policy Administration Fund Management

Charges Charges

b) if Annuity / Pension is proposed:

Target Annuity per annum Type of Annuity Annuity Amount per Defement
annum Period

Is the total insurance added to the present proposal is reasonable in relation to income
The questions above pertain to your personal condition at the time of appliction to your understanding of the
features of the product for which you are applying. This information will not be used for any other purpose and
will remain confidential.
I Sharath P, having received the informationwith respect to the above, have understood the selection of
product befor into this contract. My plan details are as following:
Plan No Plan Name Term Sum Assured
745 LIC's Jeevan Umang 71 ₹
10,00,000

Mode Premium
Monthly ₹ 16,044

KYC Details as per E-KYC

Personal Details
Pan No
JZDPS9566L

Name Date of Birth

Sharath P 16-03-1996
Gender
Male

Contact Details
C/o. House/ Bldg. / Apt.

Steert/ Road/ Lane Landmark

S/O Parameshwarappa G R, , , gavirangapura, , Gavirangapura,

Area/ Locality/ Sector Pincode

577542
Village/ Town/ City P.O.
gavirangapura

District State
Chitradurga Karnataka