LIC

LIC 300Use this form if you are taking an Insurance policy on your own life

F.No:300 (Rev-98)

LIFE INSURANCE CORPORATION

OF INDIA (Established by the Life Insurance Corporation Act, 1956)

PROPOSAL FOR INSURANCE ON OWN LIFE (Not to be used for Insurance on the Lives of Minors)DIVISIONAL OFFICE:

(All answers to be filled in legibly; Answers must begiven in words, Stroke of the pen or dots or dasheswill not be accepted as replies)

Proposal/ Policy No.

Branch Agent Code /

DO Code

/

Inward

No.

Date Is licence of Agent

in force? Initials

1 Full Name (Surname First)

and Address to Object of Insurance

which communications

are to be sent Place of Birth

. Nationality

Pin Code Sex

Telephone No. . .Permanent Residential address, if different

Nature of Age-proof submitted

from above Age (Nearer Birthday)

. Date of Birth

Pin Code . .

Telephone No. . .Short Name Father's Full Name (Surname First)

2 (a) Nominee's Full Name (Surname First) and Address

Age Relationship to yourself

. . . .

. . . .

. . . .(b) If Nominee is a Minor, Appointee's Full Name, Address, Relationship to Nominee

Age . .

. . . .

. . . .

. . . .

. .Signature of Appointee as token of consent

3

Plan & Term Sum Proposed (Rs.)

Is Accident Benefit required

If Policy is to be dated back, indicate date

Amount deposited Rs.

BOC No.

Mode Paying Authority Code Dept. No. Badge or S.R.No.

FOR OFFICE USE ONLYRid Policy Number Risk Date Plan Term PPT Sum Assured

Mode Inst. Premium

No. of Dues

Next Due DAB Prem Extra PremAge Age Proof Code

Sex Code M/NMG/NMS

R/U F/S Acceptance Code

Imp IndnEMR Code

Reins Income Code

Occ Code

Bill Type Title Rein. Dist. Taluk Vilg.

Final Underwriting Decision with Underwriter's Full Signature

Date of CompletionDate of last Payment

Date of Maturity

N.B. Rebate of premiums shall be allowed only in accordance with the details given in the prospectus or table of premium rates or, as the case may be, the relevant document, and that an offer or acceptance of any other rebates shall be an offence under Section 41 of the Insurance Act, 1938.

4(a)

Present Occupation Exact Nature of Duties

(b) Name of present employer Length of service with him

5

Educational Qualification Annual Income Rs. Source of Income Are you an Income-Tax Assessee?

6 If you are employed in the Armed Forces, please

state :

Wing to which you

belong Rank therein

Date of last medical

examination Medical category after

medical examination

Were you ever below A-1 category? If so,

when?

7. Is your life now being proposed for another assurance or an application for revival of a policy on your life under consideration in any office of the corporation? If yes, give details

8 Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation ever been :

(a) withdrawn, deferred, dropped or declined?

(b) Accepted with extra premium or lien?

(c) Accepted on terms otherwise than those proposed?

9

Please give details of your previous insurance:(including Policies Surrendered / lapsed during last 3 years)

Policy No. Office of the Corporation

Sum assured

Table & Term

Mode(Yly/Hly/qly/MlySSS)

Year of Issue MM/YY

Whether Accepted at ordinary rates

With accident benefit

Medical or non- medical

Whether in force for full Sum Assured

If not give due date of lost premium date(MM/YY)

N.B.: Corporation does not entertain any fresh proposal for insurance where a Policy has lapsed or has been converted into paid-up policy within the last 3 years.

1 Family History:

Present Age State of Health If dead, age & year of death

Cause of death

Father Mother

Brothers:

Living No.

Dead No.

Sisters: Living No. Dead No.

Wife/Husband Children: Living No.

Dead No.

11 Personal History:

(a) During the last five years did you consult a Medical Practitioner for any ailment requiring treatment for more than a week?

b) Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation?

(c) Have you remained absent from place of work on grounds of health during the last five years?

(d) Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous system?

(e) Are you suffering or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Low Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?

(f) Do you have any bodily defect or deformity?

(g) Did you ever have any accident or injury?

(h) Do you use or have you ever used: Reply

i) Alcoholic drinks

ii) Narcotics

iii) Any other Drugs

iv) Tobacco in any form

(i) What has been your usual state of health?

(j) Have you ever received or at present ailing/ undergoing Medical advice, treatment or tests in connection with Hepatitis 'B' or an AIDS-related condition?

12

In Non-Medical cases, please state exact Height in Cms., and Weight in Kgs. (without shoes):

Height Weight

13: Additional Questions in the case of Female Lives

(a) Are you pregnant now? Date of last delivery Have you had any abortion or miscarriage or Caesarian Section? If so, give details.

Date of last Menstruation

mm/dd/yy mm/dd/yy

(b) Husband's Full Name His occupation His Annual Income (Rs.)

(c) Details of Husband's insurance

Policy Number Office of Corporation Sum Assured Table & Term Present status of the Policy

DECLARATION BY THE PROPOSER

I, (name of the proposer) do hereby declare that the statements and answers under headings 1 to 7 of the proposal form have been given by me after fully understanding the questions and the same are true and complete in every particular and agree and declare that these statements and this declaration along with the statements made by the life to be assured under headings 8 to 25 of the proposal form and declaration relative thereto 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 absolutely null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

Notwithstanding 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 acknowledge or information, shall at any time be at liberty to divulge any such knowledge or information, to the Corporation.

And I further declare 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 member of his family occurs or (II) a proposal for assurance or an application for revival of a policy on the life of the life to be assured made to any office of the Corporation has been withdrawn or dropped, deferred, or declined or accepted with 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. Any omission on my part to do so shall render this Assurance invalid and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

Dated at : on the : day of :

Signature of witness

Name

Occupation

Address

Signature or thumb impression of the person whose life is proposed to be assured

If in this form the answers to the questions and/or signature(s) of the Proposer/Life to be Assured are/is in Hindi or any other Indian Language then proposer/Life to be Assured should declare in his own handwriting above his own signature(s) that all questions were explained to him and that his replies were given after fully and properly understanding the same.

1. This declaration should be made by the person filling the form:

Declarant's Name

Address

I hereby declare that I have fully explained the above questions to the proposer/Life to be assured and I have truthfully recorded the answers given by the proposer/ Life to be Assured

Signature

2. IN CASE THE PROPOSER IS ILLITERATE: The thumb impression of the proposer/Life to be Assured should be attested by a person of standing whose identity can easily be established but unconnected with the Corporation and this declaration should be made by him.

Declarant's

Name

Address

I hereby declare that I have explained the contents of the proposal form to the proposer/life to be Assured in language and that I have read out to the Proposer/Life to be Assured the answers to the questions dictated by the Proposer/ Life to be Assured and that Proposer/Life to be Assured has affixed his thumb impression on the proposal form after fully understanding the contents thereof.

Signature

FOR MEDICAL CASES ONLY

I certify that the proposer has signed in my presence after admitting that all the answers to Question Nos. 10 onwards of this form have been correctly recorded.

Signature or thumb impression of the Life Proposed

Signature of the Medical Examiner

N.B: Signature or thumb impression should be affixed in presence of Medical Examiner.

&nb/TD>

Signature or thumb impression of the Life Proposed


N.B: Signature or thumb impression should be affixed in presence of Medical Examiner.

LIC 300 BNThose taking a Bima Nivesh policy will need to use this form to apply for insurance

Form No.300 (BN) 98

LIFE INSURANCE

CORPORATION OF INDIA

(Established by the LIC Act 1956)

Branch Office: ______________________________ Proposal No:______________Agent’s Name: ____________________________

License No ……………………… Date. Of Expiry ……………………. Agent’s & DO Code.NOTE:This form has to be filled in by the proposer in his/her own handwriting. If he/she cannot write in the language of this form or he/she is illiterate, the proposal form can be filled in by the Agent/Third party as per normal rules.

1 a) Name in full (IN BLOCK LETTERS): ………………………………………………Mr. /Mrs./Miss ………………………………………………

b) Short Name ………………………………………………

c) Address for Correspondence ………………………………………………

………………………………………………

………………………………………………

d) Nationality ………………………………………………

e) Are you resident in India? ………………………………………………

f) Father’s Name in full ………………………………………………

2 a) Table/Term ………………………………..b) Sum Assured ………………………..

c) Amount of deposit ………………………..d) Date of Birth………………………….

e) Age Proof ………………………………………….. 3 a) Nominee under Section 39 of the Insurance Act, 1938, to whom policy moneys

Will be payable in the event of death.

Nominee’s full name: …………………………………………………………………(IN BLOCK LETTERS)

Age ……………………………..Relation to yourself ……………………………….

Full Address: ………………………………………………….

………………………………………………………………….………………………………………………………………….

b) Appointees Name with signature to whom the policy money is payable in the event of the claim arising during the minority of the nominee.

Full Name of the Appointee: …………………………………………………………(IN BLOCK LETTERS)

Full Address ………………………………………….……………………………………………………………………………

Signature of the Appointee ……………………………………………

Relationship to the Nominee ………………………………………….

Age of Appointee ……………………………………………………….: 2:

4 (a) Present Occupation ………………………………...

(b) Nature of duties ………………………………….

(c) Annual Income ………………………………….

(d) Total Sum Assured underPrevious policies under ………………………………………………………………Table 132

5 (a) Has a proposal on your life or an application for revival of a policy

On your life made to this or any Other Office of the Corporation everBeen ……………………………………………………..

(i) Declined : Yes/No………………………..

(ii) Accepted with extra:________________________________________(iii) If yes,

State the highest extraImposed (excluding age extra) : ………………………………….

(b) Is any proposal/application for revival pending with any office of the Corporation, if so, give the details : …………………………………..

6 Your exact Height without shoes (in cms) : …………………….

Your exact Weight (in Kgs.) : …………………….

Answer ‘Yes’ or ‘No’(If ‘NO’ give details)

7 Are you at present in good health? : ……………………………………

8 Have you ever been admitted to a Hospital/Nursing Home for takingTreatment for a week or more duringThe last 3 years? (If ‘Yes” give details) : ……………………………………

9 Have you any physical deformity?If yes, give details and totalSum Assured in force under all previousPolicies taken during last fivecalendar years including current year. : …………………………………….

10 To be answered by female proposer onlya) Total sum assured in force under all

Previous Policies taken during last5 calendar years including currentyear : …………………………………….

b) If you are married

(i) Are you pregnant now? : …………………………………….

(ii) Have you had any pregnancyrelated problems at any time : …………………………………….

: 3 :

DECLARATION BY THE PROPOSER

I …………………………………………………………………………………………….. do herebyDeclare that the foregoing statements and answers have been given by me after fully understanding questions and the same are true, and complete in every particular. I agree that if any untrue averment by contained therein the said contract shall be absolutely null and void and all moneys which have been paid in respect thereof shall stand forfeited in part or full to the Corporation.

Dated at ………………………… on the ………………. day ……………………………….. 200…..

Name of witness ………………………………………………

Signature of witness ………………………………………….

Occupation …………………………………………..

Address ………………………………………………………………………………………………………………………………………………………………………………………… Signature or thumb impression

of the person whose life isproposed to be assured

If the answers to the questions in this form are given in vernacular and the proposer signs in vernacular then the proposer signs in vernacular then the proposer should declare in his/her own handwriting above his/her own signature that all questions were explained to him/her and that his/her replies were given after fully and properly understanding the same.

OR

In case the proposer is ILLITERATE , the thumb impression of the proposer should be attested by a person of standing whose identity can easily be established but unconnected with the Corporation and this declaration should be made by him/her.

I hereby declare that I have fully explained theAbove questions to the proposer in …………….(language) and I have truthfully recorded the answers and explained to the proposer the answers to the questions dictated by the proposer and that the proposer has affixed his/her thumb impression to the proposal form after duly understanding the contents thereof.

Address of the Declarant ………………………………………………………………………………………………… ………………………………….……………………………………………………………… (Signature of the Declarant)

NOTE: In case of dispute in respect of interpretation&nble="FONT-FAMILY: Arial;mso-bidi-font-family: 'Times New

Roman'">NOTE:In case of dispute inrespect of interpretation of terms the English version shall stand valid.

LIC 340This form is to be used if you are proposing a policy on the life of someone who is over 10 years old (On the last Birthday).

LIFE INSURANCE CORPORATION OF INDIA (Established by the Life Insurance Corporation Act, 1956)

PROPOSAL FOR INSURANCE ON THE LIFE OF ANOTHER PERSON (To be used for Insurance on the Lives both of Minors & Adult)DIVISIONAL OFFICE: (All answers to be filled in legibly; Answers must begiven in words, Stroke of the pen or dots or dashes

will not be accepted as replies)

Form No.340(Rev.93)

Proposal

No. Branch

Agent Code

Number DO Code

Inward

Number Date

FOLLOWING QUESTIONS TO BE ANSWERED BY THE PROPOSER

Full Name (Surname First) and Address to which communications are to be

sent Object of Insurance

Age Sex Nationality

Pin Code Telephone No. Permanent Residential address, Relationship with Life

AssuredOccupation

2. Full name of the Life Assured Sex Nationality

Present Occupation and nature of duties

Length of service

3. Short name of Life Assured Full name (Surname first) of the father of the Life Assured

4. Date of birth of the Life

Assured Age (nearer birthday) Nature of Age Proof Place of birth

Following Questions to be Answered by the Proposer if the Life to be Assured is Minor5. If the proposal is under Children's Deferred Assurance Plan/Children's Anticipated Plan(a) State whether you wish to secure Premium Waiver Benefit in case of your death before the commencement of risk.(b) Do you agree to the condition that the policy if issued on the basis of this proposal will automatically vest in the life to be assured on the deferred date?

6 If the proposal is under any other plan, do you agree to the condition that the policy if issued on the basis of this proposal will automatically vest in the life to be assured on his/her attaining the age of majority?

7




Amount deposited Rs. BOC No.

(Years) Mode Paying Authority

CodeDept. No. Badge or S.R.No.


Mode Inst. Premium

No. of Dues


Sex Code M/NMG/NMS

RUFS Acceptance Code

Imp IndnEMR Code

Reins Income Code

Occ Code




Date of Maturity

Cash Option Deferred Date Vesting Date

8 Is your life now being proposed for another assurance or an application for revival of a policy on your life under consideration in any office of the corporation? If yes, give details

9 Please give details of your previous insurance:

Name of the divisional office of the corporation or of the

Insurer

Policy Number

Sum

Assured Plan of

Assurance Year of issue of Policy

MM/YY

Whether accepted as proposed at ordinary

rates

with Accident Benifit

Medical or non-Medical

Whether in force for the full sum

assured

If not give due date of last premium paid and mode of payment

MM/YY

*N.B.: Corporation does not entertain any fresh proposal for insurance where any previous Policy has lapsed or

has been converted into a paid up policy within the last 3 years. 10 Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation ever been:

(a) Withdrawn or dropped? (c) Accepted with an extra premium or

lien?

(b) Deferred or declined? (d) Accepted on terms otherwise than

those proposed? If yes, state If so, give details 11 Have you any prospect or intention of engaging in aviation or of entering naval or military service or taking up any other hazardous occupation or pursuit? If so

give details

12(a) What has been your usual state of health? (b) Have you any bodily defects or deformity? If so give details

(c) Have you had i) Small Pox or ii) Successful

vaccination

i)

ii)

(d) (i) Are you suffering from Pyorrhoea? (ii) State number of missing teeth, if any? (iii) For how many missing teeth a denture is worn? 13 Have you ever suffered from or are you suffering

from: If 'YES' describe fully each ailment giving its nature, the number of attacks, dates, duration, severity, treatment taken, result and names and addresses of doctors consulted.

(a) Persistent cough, asthma, bronchitis, pneumonia, pleurisy, spitting of blood, tuberculosis or any disease of lungs?

(b) High or low blood pressure, rheumatic fever pain in chest, breathlessness, palpitation, infarction or any

disease of the heart or arteries?

(c) Peptic ulcer, colitis, jaundice, anaomia, piles, dysentery or any disease of the stomach, liver, spleen, gall bladder or pancreas?

(d) Any disease of kidney, prostate, or urinary system? alysis, insanity, epilepsy, fits of any kind or nervous breakdown or any other disease of the brain or the nervous system?

(f) Hemia, hydrocele, varicocele, fistula, varicose veins, skin eruption filariasis, goitre, gonorrohea, syphilis or

any other venereal disease?

(g) Cancer, leprosy, rheumatism, gout, enlarged glands

or tumours?

(h) Any disease of the ear, nose, throat or eyes including defective sight or hearing and discharge from

the ears?

14 Have you been suspected of diabetes or are you suffering from diabetes or have you ever passed sugar,

albumin, pus or blood in urine?

15 Have you consulted a medical practitioner within the last five years of any ailments requiring treatment

for more than a week?

16 Have you remained absent from place of your work

on grounds of health during the last 5 years?

17(a) Did you ever have any operation, accident or injury? (b) Have you ever had an Electrocardiogram, X-Ray or

Screening, Blood, Urine or Stool examination? (c) Have you ever been in any hospital, asylum or sanatorium, for check-up, observation, treatment or any

operation?

18 Do you use or have you ever used alcoholic drinks, narcotics or any other drugs? If so, what? Also state

quantity consumed per day?

19 Has any of your relations, living or dead, suffered from any hereditary or infectious disease like diabetes, insanity, epilepsy, gout, asthma, tuberculosis, cancer,

leprosy etc? 20 If the proposal is to be considered without medical

report (i.e., Non-Medical basis) state: (a) Your height (without shoes) cms

(b) Your exact weight (with thin

clothes) kgs

21 Give name and address of your

usual medical attendant Full Name

Address 22 For the purpose of reference, give name and permanent address of

a friend? Full Name

Occupation Full Address 23 Family History LIVING DEAD

Age State of Health Age at Death Cause of Death

Father Mother Brothers:Living No.Dead No.

Sisters:Living No.Dead No.

Wife / Husband Children:Living No.

Dead No.

24FOR MINOR LIVES ONLY: Give below the particulars of all the assurances in full force on the lives of your

parents brothers and sisters Relationship Policy Number Sum Assured

Additional questions to be answered by Female Life to be Assured (Questions 25 to 27)

25 (a) Your Educational Qualifications b) Your average monthly income

(c) State sources of income (d) Whether you pay income tax

26 If you are married, please state (a) Husband's Full Name (b) His occupation (c) His average monthly Income Rs.

(d) Details of Husband’s insurance

Office of the Corporation Policy No. Sum Assured Plan & Term Present condition of the policy

27 For Female Cases only (a) Do you observe Purdah? (f) Have you had any abortion or

miscarriage? (b) Have the menstrual periods always been regular and painless?

(g) Did you have any complication

related to pregnancy? (c) State the date of last

Menstruation? (h) Have you any weakness or injury resulting from Child-bearing or

miscarriage?

(d) Are you pregnant now? (i) Have you suffered or are you suffering any disease of breast, overies

or uterus? (e) State the date of last delivery?

DECLARATION BY THE LIFE TO BE ASSURED

I, (Name of the Life to be assured) whose life is herein before proposed to be assured do hereby declare that the statements and answers under headings 8 to 27 of the proposal form 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.

Notwithstanding the provisions 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, executions administrators and assigns or any other person or persons having interest of any kind whatsoever in the Policy contract issued to me hereby agree hat such authority having such knowledge or information shall at any time be at liberty to divulge any such knowledge or

information to the Corporation.

Dated at On the day of , 2000


(Signature of thumb impression of the life to be Assured) I do here by declare that the foregoing statements and

answers are true and complete in every particular Occupation Address


Signature of the proposer

(If the life to be assured is under 18 years)

Occupation Address

Specimen Signature of the Life to be Assured

Specimen Signature of the Proposer

DECLARATION BY THE PROPOSER I (name of the proposer) do hereby declare that the statements and answers under headings 1 to 7 of the proposal form have been given by me after fully understanding the questions and the same are true and complete in every particular and agree and declare that these statements and this declaration along with the statements made by the life to be assured under headings 8 to 25 of the proposal form and declaration relative thereto 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 absolutely null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.And I further declare 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 member of his family occurs or (II) a proposal for assurance or an application for revival of a policy on the life of the life to be assured made to any office of the Corporation has been withdrawn or dropped, deferred, or declined or accepted with 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. Any omission on my part to do so shall render this Assurance invalid and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

Dated at On the date of , 2001

Signature of witness Signature or thumb impression of the Proposer Occupation Address

If in this form the answers to the questions and/or signature(s) of the Proposer/Life to be Assured are/is in Hindi or any other Indian Language then proposer/Life to be Assured should declare in his own handwriting above his own signature(s) that all questions were explained to him and that his replies were given after fully and properly understanding the same.1. This declaration should be made by the person filling the form:Declarant's Name Address

I hereby declare that I have fully explained the above questions to the proposer/Life to be assured and I have truthfully recorded the answers given by the proposer/ Life to be Assured

Signature

2. IN CASE THE PROPOSER AND/OR LIFE TO BE ASSURED ARE/IS ILLITERATE: The thumb impression of the proposer/Life to be Assured should be attested by a person of standing whose identity can easily be established but unconnected with the Corporation and this declaration should be made by him.Declarant's Name Address I hereby declare that I have explained the contents of the proposal form to the proposer/life to be Assured in language and that I have read out to the Proposer/Life to be Assured the answers to the questions dictated by the Proposer/ Life to be Assured and that Proposer/Life to be Assured has affixed his thumb impression on the proposal form after fully understanding the contents thereof.

Signature

N.B: Rebate of premium shall be allowed only in accordance with details given in the prospectus or table of premium rates or as the case may be in the relevant document, and that an offer or acceptance of any other

rebate shall be an offence under Section 41 of the Act

FOR MEDICAL CASES ONLY I certify that the proposer/life to be assured has/have

signed/put his/their thumb impression(s) in my presence after admitting that all the answers to Question Nos. 12 & onwards of the proposal form have been correctly

recorded. Signature or thumb impression of the Life to be

Assured before Medical Examiner Signature of the Medical Examiner

&y that the proposer/life to be assured has/have signed/put his/their thumb impression(s) in my presence after admitting that all the answers to Question Nos. 12 & onwards of the

proposal form have been correctly recorded. Signature or thumb impression of the Life to be Assured before Medical Examiner


LIC 360This form is to be used if you are proposing a policy on the life of someone who is between 1-9

years old (on the Last Birthday).

LIFE INSURANCE CORPORATION OF INDIA (Established by the Life Insurance Corporation Act, 1956)

PROPOSAL FOR INSURANCE ON THE LIFE OF ANOTHER PERSON (To be used where deferment period is 10 years or more under CDA/CAP Plan)DIVISIONAL OFFICE: (All answers to be filled in legibly; Answers must begiven in words, Stroke of the pen or dots or dashes

will not be accepted as replies)

Form No.360(Rev.93)

Proposal

No. Branch

Agent Code

Number DO Code

Inward

Number Date

1 Full Name (Surname First) and Address to which communications are to

be sent Object of Insurance

Age Sex Nationality

Pin Code Telephone No. Permanent Residential address, Relationship with Life

AssuredOccupation

2. Full name of the Life Assured Sex Nationality

Present Occupation and nature of duties

Length of service

3. Short name of Life Assured Full name (Surname first) of the father of the Life Assured

4. Date of birth of the Life

Assured Age (nearer birthday) Nature of Age Proof Place of birth

5. Is any other proposal on the life of the life to be assured now being made to or is any other proposal or an application for revival of a policy, on his life under consideration of his or any other office of the Corporation? If so which is the office and what is the amount?

6




Amount deposited Rs. BOC No.

(Years)

Mode Paying Authority Code

Dept. No. Badge or S.R.No.


Mode Inst. Premium

No. of Dues


Sex Code M/NMG/NMS

RUFS Acceptance Code

Imp IndnEMR Code

Reins Income Code

Occ Code




Date of Maturity

Cash Option Deferred Date Vesting Date

7Please give details of your previous insurance:

Name of the divisional office of the corporation or of

the Insurer

Policy Number

Sum Assured Plan of

Assurance

Year of issue of Policy

MM/YY

Whether accepted as proposed at ordinary

rates

Whether in force for the full sum

assured

If not give due date of last premium paid and mode of payment

MM/YY

*N.B.: Corporation does not entertain any fresh proposal for insurance where any previous Policy has lapsed or

has been converted into a paid up policy within the last 3 years. 8 Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation ever

been: (a) Withdrawn or dropped? (b) Deferred or declined? (c) Accepted with an extra premium or

lien? (d) Accepted on terms otherwise than

those proposed? If yes, state If Yes, state Proposal/Policy No. Name of office and year

9 Family History

of the LIVING DEAD

life to be assured Age State of Health Age at Death Cause of Death

Father Mother Brothers:Living No. Dead No.

Sisters:Living No.Dead No.

Wife / Husband Children:Living No. Dead No.

10 FOR MINOR LIVES ONLY: Give below the particulars of all the assurances in full force on the lives of your

parents brothers and sisters Relationship Policy Number Sum Assured

11 Has any of the relations of the life to be assured, living o r dead, suffered from any hereditary or infectious disease like diabetes, insanity, epilepsy, gout, asthma, tuberculosis, cancer, leprosy etc?

12Has the life to be assured come in contact during the last three years, with any person suffering from tuberculosis, leprosy or any other infectious disease? If

so, give details.

13(a) Is the life to be assured now in good health and

free from any disease? (b) Is the life to be assured of good constitution? (c) Has the life to be assured any bodily defect or

deformity? If so, give details.

(d) Has the life to be assured had (i) Small Pox or (ii)

Successful vaccination if so, (iii) When?

i)

ii)

iii)

14(a) Has the life to be assured suffered from any

illness or disease ? If so, give details.

(b) Has the life to be assured ever had any operation, accident or disease ? If so, give details (c) Has the life to be assured ever had an Electrocardiogram, X-Ray or Screening, Blood, Urine or

Stool Examination? If so, give details.

(d) Has the life to be assured ever been in any hospital, asylum or sanatorium for check-up, observation,

treatment or any operation ? If so, give details.

15(a) Is the life to be assured a student ? If so, in which

standard ?

(b) Do you wish to secure the premium Waiver Benefit in

case of your death before the commencement of risk ?

16 Do you agree to the condition that the Policy if issued on basis of this Proposal will automatically vest in

the life to be assured on the deferred date ?

DECLARATION BY THE PROPOSERI (name of the proposer) do hereby declare that the statements and answers under headings 1 to 7 of the proposal form have been given by me after fully understanding the questions and the same are true and complete in every particular and agree and declare that these statements and this declaration along with the statements made by the life to be assured under headings 8 to 25 of the proposal form and declaration relative thereto 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 absolutely null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.And I further declare 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 member of his family occurs or (II) a proposal for assurance or an application for revival of a policy on the life of the life to be assured made to any office of the Corporation has been withdrawn or dropped, deferred, or declined or accepted with 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. Any omission on my part to do so shall render this Assurance invalid and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

Dated at On the day of , 2001

Signature of witness Signature or thumb impression of the Proposer Occupation Address

If in this form the answers to the questions and/or signature(s) of the Proposer/Life to be Assured are/is in Hindi or any other Indian Language then proposer/Life to be Assured should declare in his own handwriting above his own signature(s) that all questions were explained to him and that his replies were given after fully and properly understanding the same.

1. This declaration should be made by the person filling the form:Declarant's Name Address I hereby declare that I have fully explained the above questions to the proposer/Life to be assured and I have truthfully recorded the answers given by the proposer/ Life to be Assured

Signature

2. IN CASE THE PROPOSER AND/OR LIFE TO BE ASSURED ARE/IS ILLITERATE: The thumb impression of the proposer/Life to be Assured should be attested by a person of standing whose identity can easily be established but unconnected with the Corporation and this declaration should be made by him.Declarant's Name Address I hereby declare that I have explained the contents of the proposal form to the proposer/life to be Assured in language and that I have read out to the Proposer/Life to be Assured the answers to the questions dictated by the Proposer/ Life to be Assured and that Proposer/Life to be Assured has affixed his thumb impression on the proposal form after fully understanding the contents thereof.

Signature

N.B: Reduction in premiums allowed only in case of large sums assured and for yearly mode of payments of premiums in accordance with the details given in the prospectus. Offer of any rebate is an offence under section

41 of the Insurance Act, 1938.

Signature

N.B: Reduction in premiums allowed only in case of large sums assured and for yearly mode of payments of premiums in accordance with the details given in the prospectus. Offer of any rebate is an offence under section

41 of the Insurance Act, 1938.

LIC 440This additional form is to be filled up if you are buying an Annuity based policy like Jeevan Suraksha or Jeevan Akshay

Life Insurance Corporation of India

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

(Established by the Life Insurance Corpn. Act, 1956)Office use only

Date of Receipt

Inward No.

Initials

PROPOSAL FOR AN ANNUITY

Is Licence in Force

Initials

P&GS Unit Branch Office Proposal No Details of Club Membership

Proposal No Agent's Name

Licence No. Date of Expiry

Agent's Code No. (All answers to be filled in legibly. Answers must be given in words. Strokes of Pen or dots or dashes will not be accepted as answers)

1.(a) Name in full of the person proposing to purchase the Annuity

(b) Present Address Pin Code Telephone No. (c) Permanent Address Pin Code Telephone No. (d) Age (f) i) Age Last Birthday ii) Date of Birth iii) Nature of Age proof being furnished with the proposal 2.(a) Name in full of the Annuitant, i.e., the person on whose life, annuity payments depend

(b) Present Address Pin Code Telephone No. (c) Permanent Address Pin Code Telephone No. (d) Sex (e) Nationality (f) i) Age Last Birthday ii) Date of Birth iii) What proof of age is being furnished with the proposal

3. Description of the Annuity : (a) Annuity Table Number (b) Whether Immediate or Deferred (c) Please indicate the type of annuity i) Annuity during the lifetime of the Annuitant (without any guaranteed period)? or ii) (a) Annuity for a guaranteed term of years and during subsequent lifetime of the Annuitant? (b) If so, state the guaranteed term in years, or iii) Annuity during the lifetime of the annuitant with return of cash option/Purchase Price on death of the annuitant, or

iv) Increasing Immediate Life Annuity (d) Whether annuity installments are to be paid yearly, half-yearly, quarterly or monthly (e) Amount of Annuity Installment, or, initial installment amount in case of increasing annuity (f) Dates on which Annuity installments are to be paid (g) Purchase Price (h) If a Deferred Annuity is desired, please state: i) the period after which the Annuity is to vest ii) Whether premiums are to be paid in (a) yearly, half-yearly, quarterly or monthly installments or single premium (b) amount of installment/single premium 4.(a) If proposer and annuitant are the same: Nominee to whom benefits, if any, are to be paid under the policy in case of death of the annuitant

i) Name ii) Relationship to the annuitant iii) Address Pin Code Telephone No. (b) If the proposer and annuitant are different: Nominee to whom benefits, if any, are to be paid under the policy in case of death of the annuitant while annuity is in payment

i) Name ii) Relationship to the annuitant iii) Address Pin Code

Telephone No. 5. Have any Deferred Annuity policies taken by the proponent, been surrendered during the preceding three years? If so, please furnish the following details:

Name of the Branch Office /P&GS Unit

Policy No. Purchase Price/ Cash Option

Plan No. Year & month of Issue of Policy

Year and month of surrender

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

Occupation Signature or Thumb Impression of the Proposer

Address: (the person proposing to purchase the annuity)

Occupation Name of Witness Signature of Witness: Address:

Signature of the Annuitant

If the answers to the questions in this form are given in vernacular, or if the answers are given in ENGLISH but the Proposer signs in vernacular then the proposer should declare in his own handwriting above his own signature that all questions were explained to him and that his replies were given after fully and properly understanding

the same. In case, the Proposer is illiterate:

1) This declaration should be made by the person filling in the form.

I hereby declare that I have fully explained the above questions to the proposer and I have truthfully recorded the answers given by the Proposer.

Name

Address of the Declarant Signature

2) The thumb impression of the Proposer

should be attested by a person of standing whose identity can be easily established but unconnected with the Corporation and this declaration should Be made by him.

2) I hereby declare that I have explained the contents of the proposal form to the Proposer in language and that I have read out to the proposer the answers to the questions dictated by the proposer and that the proposer has affixed his thumb impression to the proposal form after fully understanding the contents thereof.

Name and Address of the Declarant

Signature

N.B. Rebate of premium shall be allowed only in accordance with the details given in the prospectus or table of premium rates or, as the case may be, the relevant document and that an offer or acceptance of any other rebate shall be an offence under section 41 of the Insurance Act,1938.

Specimen Signature of the Annuitant

Agent's Report:1. (a) Have you canvassed the proposal yourself.

If not, state reasons therefore and who has canvassed the proposal

(b) Give marks of identification 2. (a) What is the approximate age of the Annuitant in

your opinion.

(b) Do you consider the income of the Proponent sufficient to take this Policy?

3. Do you recommend the acceptance of the Proposal

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

on this day of &D>

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

on this day of 2001.

Signature of the Agent

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