Proposal Form

Plan Details

Plan Name Plan No

LIC's Jeevan 733
Lakshya

UIN
512N297V03
Agency Code Supervisor Code Branch Code
0291323N 23063 23N

Access Id Email Id Mobile No.

2551677375 [email protected] 9450022915
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

21 - 18 ₹ 3,90,000 ₹ 1,943 ₹ 87
Total Amount Mode of Payment Date of
₹ 2,030 Monthly Commencement **
26-08-2025
AB/ADDB Req AB/ADDB Sum Assured
ADDB REQUIRED ₹ 3,90,000
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
Ankit Sharma
Father's Name Mother's Name
SHIV KUMAR SHARMA SHASHILATA SHARMA

Gender
Male Female Third Gender
Martial Status Date of birth ABHA number
Married 01-01-1990

Age (in years) Residential Status

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

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

Is the Tax Residency outside India? Yes No

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
S/O Shiv Kumar Sharma Gram Post Saravan
Address Line 3 City District
District Jalaun Jalaun Jalaun
State Country Pin Code
Uttar Pradesh India 285123
Permanent Residential Address
Address Line 1 Address Line 2
S/O Shiv Kumar Sharma, 1115, , , Saravan, Jalaun, Uttar Pradesh
sarawan,
Address Line 3 City District
sarawan Jalaun

State Country Pin Code

Uttar Pradesh India 285123

KYC Particulars

Are you an It Assessee Yes No

Proof of Identity Age proof submitted

ekyc ekyc
If Registered under GST Yes No

Occupation Details

Present Occupation Exact Nature of duties Name of the present

employer
Self-employed Business
without Income
Tax
Annual income source of income Education Purpose of insurance
Qualification
₹ 2,40,000 Self Employed Post Graduate or Risk Coverage
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
3.Hypertension, 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
9.Paralysis/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)
165 55

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 64 Good NA NA

Mother Living 60 Good NA NA

Spouse Living 30 Good NA NA

Daughter Living 8 Good NA NA

Son Living 4 Good NA NA

Son Living 1 Good NA NA

 Bank details of the life to be insured

Your bank account type Savings Current

Account Number IFSC Code Bank Name

5727380615 CBIN0282134 CENTRAL BANK OF INDIA

Nach Details
Your bank account type Savings Current

Account Number IFSC Code Bank Name

5727380615 CBIN0282134 CENTRAL BANK OF INDIA

Settlement Option

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

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 SUNITA 29 Wife ,,,, 100
DEVI

Mobile Email Bank Name Account

Number No IFSC Code
 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 Ankit Sharma 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

Ankit Sharma S/O Shiv Kumar Sharma Gram Post 285123
Saravan Jalaun Uttar Pradesh
 Suitability Analysis

Proposer Full Name Date of Birth

Ankit Sharma 01-01-1990

Age Maritial Status Occupation

36 Years Married Self-employed without Income Tax

Address
S/O Shiv Kumar Sharma Gram Post Saravan Jalaun 285123
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 0%
No

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
₹ 2,40,000
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 Lakshya
Moderate Moderate
9. Product Chosen
Plan No Plan Name Term Sum Assured
733 LIC's Jeevan Lakshya 21 ₹
3,90,000

Mode Premium
Monthly ₹ 1,943

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 Ankit Sharma, 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
733 LIC's Jeevan Lakshya 21 ₹
3,90,000

Mode Premium
Monthly ₹ 2,030

KYC Details as per E-KYC

Personal Details
Pan No

Name Date of Birth

Ankit Sharma 01-01-1990
Gender
Male

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

Steert/ Road/ Lane Landmark

S/O Shiv Kumar Sharma, 1115, , , Saravan, Jalaun, Uttar Pradesh
sarawan,

Area/ Locality/ Sector Pincode

285123

Village/ Town/ City P.O.

sarawan
District State
Jalaun Uttar Pradesh
 LIC's Jeevan Lakshya (Plan No. 733)

Benefit Illustration

LIC's Jeevan Lakshya (Plan No. 733)

A Par, Non-Linked, Life, Individual Savings Plan
(Unique Identification Number - 512N297V03)

Distribution channel Offline Agency name SEEMA SHARMA Agency code 0291323N
Name of Age of
Ankit Sharma 36 years Date of illustration 26-08-2025
prospect/policyholder prospect/policyholder
Name of life assured Ankit Sharma Age of life assured 36 years Benefit UID/Proposal no.
Mode of payment of
Policy term 21 years Premium payment term 18 years Monthly
premium

Basic sum assured Rs. 3,90,000 Sum assured on death6 4,29,000 Instalment premium 1,908.00
(at inception of the policy) Rs. (for base plan)

Bonus type Simple reversionary and final additional bonus

How to read and understand this benefit illustration?

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy, at two assumed rates of interest i.e., 8% p.a. and 4% p.a.

Some benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance business. If your policy
offers guaranteed benefits then these will be clearly marked 'guaranteed' in the illustration table on this page. If your policy offers variable benefits then the illustrations on this
page will show two different rates of assumed future investment returns, of 8% p.a. and 4% p.a. These assumed rates of return are not guaranteed and they are not the upper
or lower limits of what you might get back, as the value of your policy is dependent on a number of factors including future investment performance.

Premium summary
Particular Base plan Riders1 Total instalment premium
Instalment premium without GST 1,908.00 35.00 1,943.00
Instalment premium with GST @ 4.50% (1st year) 1,994.00 37.00 2,030.00
Instalment premium with GST @ 2.25% (2nd year onwards) 1,950.93 35.79 1,986.72
GST rate shall be as applicable from time to time.

Page 1
 LIC's Jeevan Lakshya (Plan No. 733)

(Amount in rupees)
Total benefits (including guaranteed and
Guaranteed benefits non-guaranteed benefits)
Non-guaranteed benefits @ 4% p.a. Non-guaranteed benefits @ 8% p.a.
Death benefit Maturity benefit Death benefit4
Total Total Total Total
Annualize Total maturity maturity death death
Policy income benefit, benefit, benefit, benefit,
d
year (End premium 2 Guarante benefit incl. of incl. of incl. of incl. of
of the ed Maturity Total Total
(cumulati payable Lumpsum final final final final
year) surrender in equal benefit Reversion guarantee Special guarantee Special
ve) payable Surrender Reversion Surrender additional additional additional additional
value d surrender d surrender
instalmen on date of ary bonus surrender benefit ary bonus surrender benefit bonus bonus bonus bonus
value3 value3
ts over maturity (FAB), if (FAB), if (FAB), if (FAB), if
value3 value3
o/s term any, @ any, @ any, @ any, @
after 4% 8% 4% 8%
death5 (6+7+FAB (6+11+FA (5+7+FAB (5+11+FA
) B) ) B)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18)

1 22435 0 780000 429000 0 2730 0 5545 5545 12480 0 5545 5545 0 0 431730 441480

2 44870 13738 741000 429000 0 5460 13738 11855 13738 24960 13738 11855 13738 0 0 434460 453960

3 67305 24041 702000 429000 0 8190 25346 21165 25346 37440 30005 28873 30005 0 0 437190 466440

4 89740 45792 663000 429000 0 10920 47563 30197 47563 49920 53889 41265 53889 0 0 439920 478920

5 112175 57240 624000 429000 0 13650 59503 40379 59503 62400 67586 55277 67586 0 0 442650 491400

6 134610 68688 585000 429000 0 16380 71478 51849 71478 74880 81440 71101 81440 0 0 445380 503880

7 157045 80136 546000 429000 0 19110 83496 64712 83496 87360 95494 88900 95494 0 0 448110 516360

8 179480 95815 507000 429000 0 21840 99654 79152 99654 99840 113367 108924 113367 0 0 450840 528840

9 201915 112552 468000 429000 0 24570 116891 95298 116891 112320 132388 131372 132388 0 0 453570 541320

10 224350 130324 429000 429000 0 27300 135197 113312 135197 124800 152601 156476 156476 0 0 456300 553800

11 246785 149174 390000 429000 0 30030 154627 133377 154627 137280 174104 184503 184503 0 0 459030 566280

12 269220 169082 351000 429000 0 32760 175175 155766 175175 149760 196937 215833 215833 0 0 461760 578760

13 291655 190048 312000 429000 0 35490 196855 180631 196855 162240 221166 250698 250698 0 0 464490 591240

14 314090 212040 273000 429000 0 38220 219657 208323 219657 174720 246862 289595 289595 0 0 467220 603720

15 336525 235119 234000 429000 0 40950 243657 239040 243657 187200 274150 332801 332801 0 0 469950 618150

16 358960 259256 195000 429000 0 43680 268861 273222 273222 199680 303166 380924 380924 0 0 472680 630630

17 381395 284451 156000 429000 0 46410 295302 311235 311235 212160 334054 434470 434470 0 0 475410 645060

18 403830 310662 117000 429000 0 49140 322972 353569 353569 224640 366934 494092 494092 0 0 478140 659490

19 403830 320182 78000 429000 0 51870 334218 382011 382011 237120 384347 541752 541752 0 0 480870 673920

Page 2
 LIC's Jeevan Lakshya (Plan No. 733)

(Amount in rupees)
Total benefits (including guaranteed and
Guaranteed benefits non-guaranteed benefits)
Non-guaranteed benefits @ 4% p.a. Non-guaranteed benefits @ 8% p.a.
Death benefit Maturity benefit Death benefit4
Total Total Total Total
Annualize Total maturity maturity death death
Policy income benefit, benefit, benefit, benefit,
d
year (End premium 2 Guarante benefit incl. of incl. of incl. of incl. of
of the ed Maturity Total Total
(cumulati payable Lumpsum final final final final
year) surrender in equal benefit Reversion guarantee Special guarantee Special
ve) payable Surrender Reversion Surrender additional additional additional additional
value d surrender d surrender
instalmen on date of ary bonus surrender benefit ary bonus surrender benefit bonus bonus bonus bonus
value3 value3
ts over maturity (FAB), if (FAB), if (FAB), if (FAB), if
value3 value3
o/s term any, @ any, @ any, @ any, @
after 4% 8% 4% 8%
death5 (6+7+FAB (6+11+FA (5+7+FAB (5+11+FA
) B) ) B)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18)

20 403830 370915 39000 429000 0 54600 387295 413136 413136 249600 445795 594213 594213 0 0 483600 688350

21 403830 370915 0 429000 390000 57330 390981 447330 447330 262080 462643 663780 663780 447330 663780 486330 702780

Notes:

The main objective of the illustration is that the client is able to appreciate the features of the products and the flow of the benefit in different circumstances with some level of
quantification.
This illustration is applicable to a standard (from medical, life style and occupation point of view) life.

1. It includes rider(s) premiums in respect of all the rider(s) opted by the proposer/policyholder at inception of the policy.
2. Annualized premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any, and goods & service tax. Refer
sales literature for explanation of terms used in this illustration.
3. Surrender value is higher of guaranteed surrender value (GSV) and special surrender value (SSV). SSV shall be reviewed in line with IRDAI Master Circular on Life
Insurance Products (Ref no.: IRDAI/ACTL/MSTCIR/MISC/89/6/2024 dated 12th June, 2024) and any subsequent circulars issued by IRDAI in this regard. For surrender
value calculation, it is assumed that the bonuses shall vest upon its declaration based on experience of the Corporation under this product, in the manner as per the terms
and conditions of annual valuation results.
4. In any case the total death benefit i.e. the sum of total income benefit and lump sum amount payable on maturity shall not be less than 105% of the total premiums paid
(excluding GST, extra premium and rider premiums, if any).
5. In case of death of the policyholder during the policy term, annual income benefit equal to 10% of basic sum assured shall be payable from the policy anniversary
coinciding with or following the date of death of the life assured, till the policy anniversary prior to the date of maturity. In addition to this, an amount equal to 110% of basic
sum assured (as mentioned in column no. 5) shall be payable on due date of maturity on happening of death in any of the policy years.
6. Lumpsum payable on date of maturity, on happening of death in any of the policy years, is actually payable only at the end of the policy term.
7. The actual allocation to policyholders, out of the surplus emerging from the actuarial investigation, shall be in accordance with provisions in this regard under LIC Act, 1956.

Page 3
 LIC's Jeevan Lakshya (Plan No. 733)

I, ________________________________________ (name), having received

I, ________________________________________ (name), have explained the information with respect to the above, have understood the above statement
the premiums and benefits under the product fully to the prospect/policyholder. before entering into the contract.
Place :
Place :
Date : Signature of agent/intermediary/official of the insurer Date : Signature of prospect/policyholder

Page 4
 Agents Confidential Report/Moral Hazard Report

Agency Details
Agency Code Agent Name Supervisor Code Branch Code
0291323N SEEMA SHARMA 23063 23N

Agent Mobile Agent Email Club

Membership
6393643061 [email protected]
0 No Club

Proposer Details
Name of the Proposer Age of the proposer
Ankit Sharma 35

General Plans:

Life To be Assured
1. Product related information:

Access Id Plan Term Sum Assured

2551677375 LIC's Jeevan Lakshya(Table-733) - 733 21 ₹ 390000

Whether the terms and conditions of the proposed plan have been explained to the Yes No
proposer/ life to be assured?
Whether the proposed plan matches the objectives of insurance of the proposer/ life to be Yes No
assured ?
Have you provided the Benefit Illustration statement of the proposed plan to the proposer/ Yes No
life to be assured ?
2. Information about the proposer/ Life to be assured
How long do you know the proposer/ life to be assured?:
35
Select Period
Years
Are you related to him/her? Yes No

What is the educational qualifications of the proposer/ Life to be assured ?

Post Graduate or Graduate
If proposer or the life to be insured is FNIO, whether OCI (Overseas Citizen of Yes No
India) card is verified?
Whether proposer/ Life to be assured or his / her family member/s is/are Politically Yes No
Exposed Person (PEP) as per RBI guidelines? [As per RBI guidelines PEPs are the
individuals who are or have been entrusted with prominent public functions in a foreign
Country.]
Are you satisfied that the proposer/ Life to be assured is not connected with any terrorist Yes No
activities ?
Whether KYC/ PMLA norms are fulfilled for the proposer/ Life to be assured ? Yes No

3. Financial assessment by the Agent

Exact Source of Income Income through employment/
Self Employed Business/ Profession
₹ 0
Income through HUF Income through other sources in
₹0 detail
₹ 0
Mention the proof of income verified by you in respect of income stated above
None

What is the PAN number?

Whether verified and compared with the PAN mentioned in the Income Proof? Yes No

Are you personally satisfied with the financial standing of the proposer/life assured and Yes No
justify the current proposal ?
4. Previous insurance details including from other insurers
Did you discuss with the proposer/Life to be assured the status of Previous Policies and Yes No
are you satisfied that no policy has lapsed within the last three years ?
Are you aware of any Proposal (or Revival of any policy) of the proposer/ life to be assured Yes No
having been deferred, declined, dropped or accepted at terms other than those proposed
?
5. Information about health , Habit and occupation/ avocation etc
What is the general state of health of the life to be assured? Good Not
Good

Does he/she have any physical deformity or Mental Retardation ? Yes No

Do you have any knowledge of his/her having suffered from any illness or injury or Yes No
undergone any operation or medical investigation?
Height of the life to be assured ( in Cms) Weight of the life to be assured ( in
Kgs)
165
55
Are you aware of anything in the occupation, financial or social position of the life to be Yes No
assured, his/her personal habits or any other circumstances which might be likely to add
to the risk ?
Any other infromation
 Declaration

I further hereby declare that the foregoing statements are true and correct to the best of my knowledge and
belief

Signature
✔Verified through OTP
By : SEEMA SHARMA - 0291323N
Date and time : 26-08-2025 15:58:50

To be completed by the Dev.Officer/ CLIA / Mentor To be completed by ABM(S) / BM / Sr.BM / CM

I am satisfied with the identity of the party on the I am satisfied with the identity of the party on the
basis of my independent enquiries. I here by declare basis of my independent enquiries. I here by declare
that the foregoing statements are true and correct to that the foregoing statements are true and correct to
the best of my knowledge and belief. the best of my knowledge and belief.
Dated at ........................on the day of ............ 20.. Dated at ........................on the day of ............ 20..
Name and Designation/Standing (No of years) Name and Designation/Standing (No of years)
Signature Signature