LIFE INSURANCE CORPORATION OF INDIA (Estd Under LIC Act 1956) Mr.

Ankit Agarwal
FORM FOR SUITABILITY ANALYSIS Access Id : 844200629

Proposer Full Name Date of Birth Age Marital Status Occupation

Details : Mr. Ankit Agarwal 09-12-1995 28 Married 02-Service(Listed Companies/Institutions

Address : 329 3rd FLOOR, MEGA DREAM HOME APARTMENT, KARAMCHARI NAGAR BAREILLY, 243001

2. What is proposer's yearly income from: ( ** if life assured is different from the proposer)
Employment Business / Profession Other Sources H.U.F. If any Income of life to be assured **
600000 0 0 0 0
3. Whether income proof submitted ? (If Yes, give details below) No
Nature of Document for income verification Is he/she Income Tax Assessee If yes, please provide PAN & Income Tax Bracket

No Income Proof submitted Yes BNSPA2950H Nil

4. Previous Insurance Details (Please refer annexure)
5. Family History (Please refer annexure)
Spouse Details
Name Occupation Annual Income
HARSHITA AGARWAL N.A. N.A.
6. Need Analysis
Total Annual Income Outstanding Liabilities
600000 Secured Loans 0 Non-secured Loans 0
Based on his age and income, the maximum insurance that can be granted is :
Age Group Multiple of Avg. Annual Income Maximum allowable Insurance
Up to 35yrs 25 times 15000000

7.
Object of Insurance How would you like to pay your premiums
Market linked Return with Risk cover Regular
Risk Profile Time frame for this investment
Aggressive 15
8 Categorization of Plans in relation to object of Insurance
Category Risk Profile Plan Name
Aggressive Aggressive LICs INDEX PLUS

9 Product Chosen
Table No Plan Name Term Sum Assured Mode Premium
873 LIC's Index Plus 15 300000 Monthly 2500

a) If ULIP is proposed :
Allocation Charges Other Charges (which will be levied by cancelling Units)
Ist Year Iind Year IIIrd Year onwards Life Cover charges Policy Administration Charges Fund Management charges
N.A. N.A. N.A. N.A. N.A. N.A.
b) If Annuity / Pension is proposed :
Target Annuity per annum Type of annuity Annuity Amount per annum Deferment Period
N.A. N.A. 0 N.A.

10. Is the total insurance added to the present proposal is reasonable in relation to income Yes

The questions above pertain to your personal condition at the time of application and 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, Mr. Ankit Agarwal having received the information with respect to the above , have understood the
selection of product before entering into this contract. My preferred plan details are as following:

Table No Plan Name Term Sum Assured Mode Premium

873 LIC's Index Plus 15 300000 Monthly 2500

26-03-2024 [Link]
 LIC's Index Plus (Plan No. 873)

Benefit Illustration

LIC's Index Plus (Plan No. 873)

A Unit Linked, Non-participating, Individual, Life Insurance Plan
(Unique Identification Number - 512L354V01)

Distribution channel Offline Agency name Agency code

Name of prospect Age of prospect 28 years Date of illustration 26-03-2024
Name of life assured Age of life assured 28 years Benefit UID ON348397416152
Mode of payment of
Policy term 15 years Premium paying term 15 years Monthly
premium
Sum assured 3,00,000 Instalment premium 2,500.00 GST rate 18.00%
Investment strategy
Fund opted Flexi smart growth fund Risk level Very high risk Self managed
opted for
LIC's Linked ADB rider Opted AB rider sum assured 3,00,000
Death benefit option 2 Sum assured multiple 10

How to read and understand this benefit illustration?

This benefit illustration is intended to show what charges are deducted from your premiums and how the unit fund, net of charges and taxes, may grow over the years of the
policy term if the fund earns a gross return of 8% p.a. or 4% p.a. These rates, i.e., 8% p.a. and 4% p.a. are assumed only for the purpose of illustrating the flow of benefits if
the returns are at this level. It should not be interpreted that the returns under the plan are going to be either 8% p.a. or 4% p.a.

Net yield mentioned corresponds to the gross investment return of 8% p.a., net of all charges but does not consider mortality, morbidity charges, underwriting extra, if any,
guarantee charges and cost of riders, if deducted by cancellation of units. It demonstrates the impact of charges exclusive of taxes on the net yield. Please note that the
mortality charges per thousand sum assured in general, increases with age.

The actual returns can vary depending on the performance of the chosen fund, charges towards mortality, morbidity, underwriting extra, cost of riders, etc. The investment risk
in this policy is borne by the policyholder, hence, for more details on terms and conditions please read sales literature carefully.

Part A of this statement presents a summary view of year-by-year charges deducted under the policy, fund value, surrender value and the death benefit, at two assumed rate
of return. Part B of this statement presents a detailed break-up of the charges, and other values.

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 LIC's Index Plus (Plan No. 873)

Part A:

(Amount in rupees)

At 4% p.a. gross investment return At 8% p.a. gross investment return

Other Other
charges charges Commissio
(including (including n (incl.
GST GST bonus
Annualized FMC and FMC and
Policy year (excluding (excluding commission
premium GST on GST on
Mortality GST on Fund at end Surrender Death Mortality GST on Fund at end Surrender Death ) payable to
FMC but FMC but
charges FMC and of year value benefit charges FMC and of year value benefit intermediar
excluding discontinua excluding discontinua
discontinua nce charge) discontinua nce charge) y
nce charge nce charge
and its and its
GST)* GST)*
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15)

1 30000 363 2750 519 26938 23398 300000 362 2754 519 27498 23958 300000 1050

2 30000 332 2441 378 55446 53086 300000 331 2463 378 57683 55323 300000 1050

3 30000 302 2899 373 84664 82894 300000 298 2958 372 89810 88040 300000 1050

4 30000 271 3368 367 114610 113430 300000 262 3485 366 124006 122826 300000 1350

5 30000 238 3850 362 145304 145304 300000 222 4045 358 160407 160407 300000 1350

6 30000 203 4862 450 177038 177038 300000 176 5162 445 199416 199416 300000 1350

7 30000 164 5420 451 208611 208611 300000 123 5850 444 239989 239989 300000 1350

8 30000 120 5979 453 240923 240923 300000 62 6566 442 283131 283131 300000 1350

9 30000 72 6551 454 273992 273992 300000 5 7327 442 328996 328996 328996 1350

10 30000 23 7138 455 309634 309634 315000 0 8135 451 379489 379489 379489 1350

11 30000 9 7769 463 344266 344266 346500 0 9021 462 431293 431293 431293 1350

12 30000 2 8387 473 379651 379651 379651 0 9932 473 486285 486285 486285 1350

13 30000 0 9020 485 415797 415797 415797 0 10898 485 544664 544664 544664 1350

14 30000 0 9668 497 452716 452716 452716 0 11922 497 606638 606638 606638 1350

15 30000 0 10332 510 496122 496122 496122 0 13009 510 677871 677871 677871 1350

*See 'Part B' for details

Force Majeure Conditions:

a. The Corporation shall value the funds (SFIN) on each day for which financial markets are open. However, the Corporation may value the SFIN less frequently in extreme

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 LIC's Index Plus (Plan No. 873)

circumstances external to the Corporation, i.e. in force majeure events, where the value of the assets is too uncertain. In such circumstances, the Corporation may defer
the valuation of the assets for up to 30 days until the Corporation is certain that the valuation of SFIN can be resumed.
b. The Corporation will inform IRDAI of such deferment of the valuation of assets. During the continuance of the force majeure events, all requests for servicing the policy,
including policy related payment, shall be kept in abeyance.
c. The Corporation will continue to invest as per the investment pattern of the fund type opted by the policyholder. However, the Corporation reserves the right to change the
exposure of all or any part of the fund to money market instruments (as defined under Regulations 2(j) of IRDAI(Investment) Regulations, 2016) in circumstances
mentioned under points (a) and (b) above. The exposure of the chosen fund shall be reinstated within reasonable timelines once the force majeure situation ends.
d. Few examples of such circumstances as mentioned in point (a) & (b) above are:
i. When one or more stock exchanges which provide a basis for valuation of the assets of the fund are closed otherwise than for ordinary holidays.
ii. When, as a result of political, economic, monetary or any circumstances which are not in the control of the Corporation, the disposal of the assets of the fund would be
detrimental to the interests of the continuing policyholders.
iii. In the event of natural calamities, strikes, war, civil unrest, riots and bandhs.
iv. In the event of any force majeure or disaster that affects the normal functioning of the Corporation.
e. In such an event, an intimation of such force majeure event shall be uploaded on the Corporation’s website for information.

IN THIS POLICY, THE INVESTMENT RISK IS BORNE BY THE POLICYHOLDER AND THE ABOVE INTEREST RATES ARE ONLY FOR ILLUSTRATIVE PURPOSE.

I, ________________________________________ (name), have explained I, ________________________________________ (name), having received

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

Page 3
 LIC's Index Plus (Plan No. 873)

Part B:

(Amount in rupees)

Gross yield (p.a.) 8.00% Net yield (p.a.) 5.78%

GST
(excluding
Premium Accident FMC
Annualize allocation dAnnualize GST on Policy Addition Fund (including Fund after Guarantee Refund of Fund at
Policy Mortality benefit Surrender Death
premium FMC and admin to the before d addition mortality end of
year d premium charge charge rider tax charge FMC value benefit
less PAC discontinu charge fund FMC charge year
(PAC) charge on FMC)
ance
charge)
(12)=(10)-
(1) (2) (3) (4)=(2)-(3) (5) (6) (7) (8) (9) (10) (11) (13) (14) (15) (16) (17)
(11)
1 30000 2400 27600 362 519 0 120 1133 27732 234 27498 0 0 27498 23958 300000

2 30000 1650 28350 331 378 0 120 3356 58375 693 57683 0 0 57683 55323 300000

3 30000 1650 28350 298 372 0 120 5755 90998 1188 89810 0 0 89810 88040 300000

4 30000 1650 28350 262 366 0 120 8308 125721 1715 124006 0 0 124006 122826 300000

5 30000 1650 28350 222 358 0 120 11026 162682 2275 160407 0 0 160407 160407 300000

6 30000 1200 28800 176 445 975 120 13892 201383 2867 198516 900 0 199416 199416 300000

7 30000 1200 28800 123 444 1024 120 16990 243495 3506 239989 0 0 239989 239989 300000

8 30000 1200 28800 62 442 1075 120 20213 287302 4172 283131 0 0 283131 283131 300000

9 30000 1200 28800 5 442 1129 120 23639 333875 4879 328996 0 0 328996 328996 328996

10 30000 1200 28800 0 451 1185 120 27279 383319 5630 377689 1800 0 379489 379489 379489

11 30000 1200 28800 0 462 1244 120 31286 437749 6457 431293 0 0 431293 431293 431293

12 30000 1200 28800 0 473 1307 120 35397 493590 7305 486285 0 0 486285 486285 486285

13 30000 1200 28800 0 485 1372 120 39761 552870 8206 544664 0 0 544664 544664 544664

14 30000 1200 28800 0 497 1440 120 44394 615800 9162 606638 0 0 606638 606638 606638

15 30000 1200 28800 0 510 1513 120 49312 682607 10177 672430 3600 1841 677871 677871 677871

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 LIC's Index Plus (Plan No. 873)

(Amount in rupees)

Gross yield (p.a.) 4.00%

GST
(excluding
Premium Accident FMC
Annualize allocation dAnnualize GST on Policy Addition Fund (including Fund after Guarantee Refund of Fund at
Policy Mortality benefit Surrender Death
premium FMC and admin to the before d addition mortality end of
year d premium charge charge rider tax charge FMC value benefit
less PAC discontinu charge fund FMC charge year
(PAC) charge on FMC)
ance
charge)
(12)=(10)-
(1) (2) (3) (4)=(2)-(3) (5) (6) (7) (8) (9) (10) (11) (13) (14) (15) (16) (17)
(11)
1 30000 2400 27600 363 519 0 120 570 27169 230 26938 0 0 26938 23398 300000

2 30000 1650 28350 332 378 0 120 1659 56117 671 55446 0 0 55446 53086 300000

3 30000 1650 28350 302 373 0 120 2792 85793 1129 84664 0 0 84664 82894 300000

4 30000 1650 28350 271 367 0 120 3953 116208 1598 114610 0 0 114610 113430 300000

5 30000 1650 28350 238 362 0 120 5143 147383 2080 145304 0 0 145304 145304 300000

6 30000 1200 28800 203 450 975 120 6349 178705 2567 176138 900 0 177038 177038 300000

7 30000 1200 28800 164 451 1024 120 7609 211688 3077 208611 0 0 208611 208611 300000

8 30000 1200 28800 120 453 1075 120 8863 244506 3584 240923 0 0 240923 240923 300000

9 30000 1200 28800 72 454 1129 120 10146 278094 4102 273992 0 0 273992 273992 300000

10 30000 1200 28800 23 455 1185 120 11459 312468 4633 307834 1800 0 309634 309634 315000

11 30000 1200 28800 9 463 1244 120 12873 349471 5205 344266 0 0 344266 344266 346500

12 30000 1200 28800 2 473 1307 120 14247 385411 5761 379651 0 0 379651 379651 379651

13 30000 1200 28800 0 485 1372 120 15650 422125 6328 415797 0 0 415797 415797 415797

14 30000 1200 28800 0 497 1440 120 17084 459623 6908 452716 0 0 452716 452716 452716

15 30000 1200 28800 0 510 1513 120 18548 497922 7500 490422 3600 2100 496122 496122 496122

Notes:

1. Refer the sales literature for explanation of terms used in this illustration.
2. The above illustrations are for indicative purpose. The annual charges shown above are sum total of charges deducted throughout the policy year as per the
frequency/conditions detailed in sales brochure/policy document.
3. This illustration is prepared by considering standard life (from medical, life style and occupation point of view).
4. In case LIC's Accidental Death Benefit rider is opted for, rider charges are included in other charges under part A. However, under part B, accident benefit rider charge is
shown separately.
5. Fund at the start shall be the amount available for investment in the first year and previous year's end fund for rest of the years.

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 LIC's Index Plus (Plan No. 873)

6. Above calculations have been performed considering deductions of mortality charge, policy administration charges and tax charge on these charges at the start of each
policy month and deduction of FMC and Tax charge on FMC the end of each policy month.
7. Tax charge (currently GST) is subject to change from time to time.
8. Total death benefit is the amount payable immediately on death of the life assured, which is higher of (basic sum assured reduced by partial withdrawal made during the
two years period immediately preceding the date of death) or unit fund value or (105% of the total premiums received reduced by partial withdrawal during the two years
period immediately preceding the date of death), where basic sum assured is (7 times of annualized premium), for age greater than 50 years and (7 or 10 times of
annualized premium as per the choice), for age less than or equal to 50 years.
9. The death benefit has been calculated assuming that death occurs on completion of the policy year and the option of partial withdrawal has not been exercised.
10. In addition to death benefit, accident benefit sum assured is payable as per terms and conditions of the policy, if LIC's Accidental Death Benefit rider is opted for and
death occurs due to accident.
11. The above illustration assumes the policy is surrendered on completion of the policy year after addition of guaranteed addition in unit fund. In case the policy is
surrendered on or before 5 years' lock-in-period, surrender value shown above equals unit fund value at the end of policy year minus discontinuance charge minus tax
charge on discontinuance charge. This amount shall be transferred to the discontinued policy fund and the proceeds of the discontinued policy fund shall be payable on
completion of 5 years' lock-in-period. In case the policy is surrendered after expiry of 5 years' lock-in-period, the surrender value shall be payable immediately.
12. For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale.

I, ________________________________________ (name), have explained I, ________________________________________ (name), having received

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

Page 6
 ONLINE PROPOSAL FORM

Plan Name LIC's Index Plus Plan No 873 UIN 512L354V01

Proposal No. 800907 Proposal Date Recent Passport size

photograph of the
Access_Id Customer Portal ID proposer
844200629 844200629

Email Id 0912ankitagarwal@[Link] Mobile No. * 8266959343

* 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.
▼ Details of plan proposed
Term Sum Assured Premium Mode of Payment

15 300000 2500 Monthly

Sum Assured Option Option I (7 Times of annualized Premium)

✔ Option II (10 Times of annualized Premium)

LIC's Linked Accident Death Benefit Required Y/N Yes If yes, Accident Benefit Sum Assured
300000
Are you are engaged in Police duty, in any police organization other than paramilitary force Yes ✔ No
Do you wish to avail the LIC's Linked Accident Death Benefit while on police duty N.A.

▼ Personal details of the life to be insured

1. Name of the Life to be Assured Mr. Ankit Agarwal
2. Father's Name
ANIL AGARWAL
3. Mother's Name
SEEMA AGARWAL
4. Spouse Name *
HARSHITA AGARWAL

5. Gender ✔ Male Female

6. Qualification Graduate Or Post Graduate 7a. Date of birth 09-12-1995 7b. Age 28

Aadhar with full DOB BAREILLY

8. Age Proof 9. Place of birth
Married Market linked Return with Risk cover
10. Marital Status 11. Objective of Insurance

▼ Communication details
12. Present Address for communication 13. Permanent Residential Address

Address Line-1 Address Line-1

329 3rd FLOOR Flat 801 Tower A2 Gaur City 2 J.K.G

Line-2 Line-2
MEGA DREAM HOME APARTMENT Palm Court Greater Noida West Gautam

Line-3 Line-3
KARAMCHARI NAGAR BAREILLY Buddha Nagar Uttar Pradesh

PIN Code PIN Code

243001 201009

Phone (Landline) Phone (Landline)

00 0

▼ Identification particulars

14. Residential Status Resident Indian 15. Country of Residence India

16. Aadhar Card No 17. PAN BNSPA2950H

18 a. Address Proof Aadhaar Card/e-Aadhaar Card 18 b. Identification Proof Aadhaar Card/e-Aadhaar Card

Page 1 of 7
India
 Proposal Form

▼ Employment details of the life to be insured

17. Occupation Service(Listed Companies/Pvt Institutions) 18. Nature of work Service

19. Name of present 20. Length of service

employer GENPACT INDIA PVT LTD NOIDA 12 months

21. Annual income 22. Source of income

600000 Employed(Salary)

23 a. Is your occupation associated with any specific hazard or do you take part in hazardous activities or
have hobbies that could be dangerous in any way ?
Yes ✔ No

If yes, provide details

23 b. Are you Politically Exposed Person (PEP as per RBI Guidelines PEPs are the individuals who are
or have been entrusted with prominent public functions in a foreign country.)
Yes ✔ No

If yes, provide details

23 c. Are you (Proposer) registered under the GST act ? Yes ✔ No

If yes, provide GSTIN

24. Are you employed in armed forces?

Yes ✔ No
(If your answer is 'Yes', please provide the following details:

(a) Wing to which you (b) Date of last medical

belong? examination

(c) Rank therein (d) Medical category after

medical exam

(e) Were you ever (f) If yes, when.

below A-1 category? (please provide date)

▼ Lifestyle details
25a.

Do you smoke / consume or have you ever Yes / No If YES, Quantity consumed If STOPPED,
smoked / consumed the following (i , ii, iii) and Duration Since how may months

(i) Alcoholic drinks

Yes ✔ No
(ii) Narcotics
Yes ✔ No
(iii) Any other drugs
Yes ✔ No

25b.
Do you smoke/consume or have you
smoked/consumed tobacco in any form ( cigars,
cigarettes, beedis, pan masala etc) in the past Yes ✔ No
60 months.(in sticks/packets/ sachets/gms per
day)

26. Have you ever been or are currently being investigated,

chargesheeted, prosecuted or convicted in respect of any Yes ✔ No
criminal/civil offences in any court of law of India or abroad?

If yes, provide details

Page 2 of 7
 Proposal Form

▼ Fund Type

27. Fund Type Flexi Smart Growth Fund

▼ BROAD INVESTMENT PATTERN OF THE INVESTIBLE FUNDS
Fund Type Investment in Short-term Investment in Details and objective of the fund Risk Profile SFIN
Government/ investments such as Listed Equity for risk /return
Government money market Shares
Guaranteed instruments
Securites/ Corporate
Debt

Flexi Growth 0% to 20% 0% to 40% 40% to 100% To provide long term capital Very ULIF00510/11
Fund appreciation through investment High /23
primarily in select stocks which are Risk LICULIPFLX5
a 12
part of NSE NIFTY100 Index.

Flexi Smart 0% to 20% 0% to 40% 40% to 100% To provide long term capital Very ULIF00610/11
Growth Fund appreciation through investment High /23
primarily in select stocks which are Risk LICULIPFSG5
a 12
part of NSE NIFTY50 Index.

▼ Nominee / Appointee details

28. For Nomination and Appointee details, please see annexure

▼ Details of previous policies held / proposals applied

29. For the list of Previous Policies, kindly refer annexure

30 Whether proposed simultaneously on the life of spouse / children /parents ? Yes ✔ No

If yes, please give details

31. Is your life now being proposed for another assurance or an application for revival
of a policy on your life or any other proposal under consideration in any office of
Yes ✔ No
Life Insurance Corporation of India or to any other insurer?
If yes, please give details

32. Has a proposal (or an application for revival of a policy) on your life made to any office of Life Insurance Corporation
of India or to any other insurer ever been:
Yes ✔ No
(a) Withdrawn, Deferred, Dropped or Declined?

If yes, please give details

(b) Accepted with extra Premium or Lien? Yes ✔ No

If yes, please give details

(c) Accepted on terms otherwise than those proposed? Yes ✔ No

If yes, please give details

(d) Have you during past one year returned any policy of Life Insurance Corporation of Yes ✔ No
India as the same was not acceptable to you?

If yes, please give details

Page 3 of 7
 Proposal Form

▼ Medical details of the life to be insured

33. 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.

a) . Lungs/ Respiratory Disease / Persistent cough, asthma, bronchitis, pneumonia, spitting of blood etc
Yes ✔ No

b). Hypertension, Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, any disease of Yes ✔ No
the heart or arteries?

c). Peptic ulcer/colitis, jaundice, anaemia, piles, dysentery, or any other disease of the stomach, liver,
spleen, gall bladder or pancreas/ digestive disorder
Yes ✔ No

d). Any disease of kidney /prostate or urinary system? Yes ✔ No

e). Paralysis/epilepsy/ insanity/ tremors, numbness, double vision, dizzy or fainting spells/ head Injury / Yes ✔ No
insomnia/ nervous breakdown / any other disease of the brain or the nervous system

f). Hernia/hydrocele, varicocele, fistula, varicose veins, filariasis, gonorrhoea, syphilis or any other Yes ✔ No
venereal disease?

g) Cancer/leukemia/lymphoma/ tumour / cyst/ Any other growth / lumps/ blood disorder /enlarged glands Yes ✔ No

h) Any disease of ear, nose, throat or eyes, including defective sight or hearing and discharge from the Yes ✔ No
ears

i) Endocrine disorders such as Diabetes, Goitre, Thyroid etc or ever passed sugar, albumin, pus or blood Yes ✔ No
in urine

j). Bone / Joint/ Spine Disease/ Arthritis Yes ✔ No

k). Mental Disorder (Depression/ Anxiety, etc.) Yes ✔ No

l). Chronic infections- Tuberculosis/ pleurisy / Skin Disease/ skin eruption/ Leprosy. Yes ✔ No

m). Hepatitis or AIDS & HIV related condition Yes ✔ No

n). Any Operation, accident or injury/ any bodily defect or deformity. Yes ✔ No

l) Any other disease? Yes ✔ No

Page 4 of 7
 Proposal Form

▼ Medical details of the life to be insured

34. Height (in cms) 175 `` Weight (in kgs) 75

34.a. What has been the Life to be assured’s usual state of health? ✔ Good Not Good

35. During the last five years did you consult a Medical Practitioner for any ailment requiring Yes ✔ No
treatment for more than a week ?

If yes, please give details

36. Have you ever been admitted to any hospital or nursing home for general check up, Yes ✔ No
observation, treatment or operation?
If yes, please give details

37. Have you remained absent from place of work on grounds of health during the last 5 years ? Yes ✔ No
If yes, please give details
▼ Settlement Option

Do you wish to avail Settlement option to take Death Benefit in Instalments Yes ✔ No
If yes, please give the following details :

1. Period of Settlement Option to take Death Benefit in Instalments (maximum 5 years)

N.A.

2. Mode of Instalment payment N.A.

Note : The Instalment shall be the total number of units as on the date of intimation of death divided by total number of instalments (i.e.
5,10,20 and 60 for yearly, half-yearly, quarterly and monthly instalments in 5 year period respectively). The number of units arrived at in
respect of each instalment will be multiplied by the NAV of the applicable fund type as on the date of instalment payment. The first
payment will be made corresponding to the date of intimation of death and thereafter based on the mode opted by the policyholder i.e.
Every month or three months or six months or annual from the date of intimation of death, as the case may be.

▼ Family Details :
38. Have your parents / brothers / sisters / spouse / children ever suffered from or died of heart disease, stroke,
high blood pressure, diabetes mellitus, any form of eye disease, cancer, kidney disease or paralysis or any Yes ✔ No
hereditary disorders, tuberculosis, or any contagious diseases such as hepatitis, AIDS / HIV etc.?
If Yes, please give details

a) Name of the disease N.A.

b) Relationship to the life to be assured N.A.

c) date / year of death````` N.A.

▼ Female Life
Please refer to annexure “Female Life”

▼ Bank details of the life to be insured

44. Your bank account type 45. Account Number

✔ Savings Current 50100336169611

46. IFS Code 47. Bank Name

HDFC0006303 HDFC BANK

48. Bank Address

Page 5 of 7
 Proposal Form

▼ 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 ; and
(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.

(3) 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 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 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 Signature of the Agent /

Life to be Assured Intermediary

Page 6 of 7
 Proposal Form

▼ Declaration of the life to be insured

Ankit Agarwal
I __________________________________________ authorize LIC of India to take my KYC details of Aadhaar from the Unique Identification
Authority of India (UIDAI).
Ankit Agarwal
I ___________________________________________the proposer / 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 and/or
employer from divulging any knowledge or information about me concerning my health or employment on the grounds of secrecy. 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 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 the
occupation of the life to be assured or any adverse circumstances connected with the financial position or general health of the life to be
assured or that of any members of family of the life to be assured occurs or (ii) if a proposal for assurance or any application for revival of a
policy on the life to be assured made to any office of the Corporation or to any other life insurer has been withdrawn or dropped, deferred or
accepted at an increased premium or subject to a lien 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. And if any such omission on my part or any untrue averment contained therein is
established by the Corporation, the said contract shall be dealt with as per provisions of Section 45 of the Insurance Act, 1938, as amended
from time to time.
I hereby give my consent for undergoing medical examinations / tests including test for HIV as required by the Corporation.

I further declare that I have discussed my financial standing with the agent/intermediary. I have been informed about the risk profile of the ULIP
plan(s) and fund(s). In consultation with the agent/intermediary, I have taken a personal and independent decision in an informed manner to go
for the Plan and Fund which I have chosen.

I understand that if I have deposited “application money” as a token consideration under this proposal for insurance, the closing NAV of the date
of completion only will be applied for allotment of units.

✔ I have read the declaration and summary of Section 41 and Section 45 of Insurance Laws(Amendment) Act, 2015 and agree with the terms and conditions.
✔ I have understood fully the terms and conditions of the plan I propose to take
Signature of witness

Name Witness should be a third party (Not related to the life to be insured) Signature of the life to be insured

Address

Pin Code

1. Declaration by the person filling in the form (in case form is filled up/signed in a language different from that of the Proposal Form or
in case the proposer is person with disability (PWD) where he/she is not able to fill the proposal form himself/herself.)
I here by declare that I have fully explained the above questions to the proposer and I have truthfully recorded the answers given by the proposer
and the proposer has affixed the thumb impression / signature as below after fully understanding the contents thereof.
Name of the Declarant:..................................................

Address of the Declarant:.................................................. Signature :...........................................

I certify that the contents of the form and documents have been fully explained to me by (Name, Designation, Occupation)
Mr./Mrs................................................................................................................ and I have understood the significance of the proposed contract.

___________________________________________________________________
(Signature or thumb impression of the person whose life is proposed to be assured:)
2. In case the proposer is illiterate, his/her thump impression should be attestted by a person of standing whose identity can be
establised, but unconnected with the Corporation and this declaration should be made by him.
I hereby declare that I have fully explained the above questions and contents of the proposal form to the proposer in
____________________________ language, and that the proposer has affixed the thumb impression above after fully understanding the contents
thereof.
Name of the declarant :............................................................ Signature....................................................

Address of the declarrant..........................................................

Residence for Tax Purposes in Jurisdiction(s) outside India (Not applicable for Plans 955,954/854 and 859) Yes ✔ No
I hereby declare that the detail furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any
changes therein within 30 days of such changes. In case any of the above information is found to be false or untrue or misleading or
misrepresenting, I am aware that I may be held liable for it

Page 7 of 7
 NOMINATION DETAILS
Ankit Agarwal Proposal Form

Access Id : 844200629

▼ Particulars of Nomination

Sl Name of the Nominee Age Relationship Share Full Communication Address of the Nominee with PINCODE.
No to the life (%)
assured

329 3rd FLOOR MEGA DREAM HOME KARAMCHARI

1 HARSHITA AGARWAL 28 Wife 100 243001
APARTMENT NAGAR BAREILLY

▼ Particulars of Appointee (when nominee is minor)

Sl Name of the Appointee Age Relationship to the Full Communication Address of the Appointee with PINCODE.
No nominee

Page 1 of 1
 FAMILY HISTORY

Ankit Agarwal

Access Id : 844200629

Relationship Living / Present State of Health Age at Cause of Death

Dead Age Death

Father Dead 0 45 HEART FAIL

Brother Living 31 Good 0

Mother Living 54 Good 0

Wife Living 28 Good 0

2024-03-26 Page 1 of 1
 PREVIOUS POLICIES ANNEXURE

Ankit Agarwal

Access Id : 844200629

Sum Date of
Policy No. Insurer Plan How Accepted Status
Assured Commencement

208691928 LIC 815 200000 2018-11-12 Accepted at OR Inforce

[Link].0

227421521 LIC 815 100000 2017-05-28 Accepted at OR Inforce

[Link].0

Page 1 of 1
 e-KYC DETAILS FROM UIDAI

Access Id : 844200629

▼ Personal Details

Aadhaar No. / Virtual ID : ********4765

Name :` Ankit Agarwal Photo

09-12-1995
Date of Birth : Gender : MALE

▼ Contact Details

C/o.

House / Bldg. / Apt. Flat 801 Tower A2

J.K.G Palm Court

Street / Road / Lane

Landmark

Gaur City 2
Area / Locality / Sector

201009
Pincode

Village / Town / City Greater Noida West

P.O.

Gautam Buddha Nagar

District

Uttar Pradesh
State

Page 1 of 1