Affix here

Spouse’s Affix here

recent Proponent’s
passport size recent
photograph passport size
DEPARTMENT OF POSTS (In case of YS photograph
PROPOSAL FORM FOR POSTAL LIFE INSURANCE Proposal only)
(All entries should be filled in CAPITAL letter)
[Questions 12, 12.1, 13 & 14 relate to proposals for Sum Assured/Aggregate Sum assured above `20 lakh]

FOR OFFICIAL USE ONLY

Name of the Development Officer/ FO/ Agent/ Postal Employee Proposal No.
(ASP/ IPO/ PM/ PA/ SA/ Postman/ Mail Guard/ MTS/ GDS BPM/ GDS
DA/ GDS MC)
Date of Receipt
No. of LI-7(a)
Amount deposited `
DO/FO/Postal Employee/GDS/Agent/Sales Force Code Post Office at which deposited

Receipt No. and Date

Policy No.

Proposal Date (DD/MM/YYYY) Date of Declaration (DD/MM/YYYY)

/ / / /
Product/ Policy Type WLA CWA EA AEA YS
1. Proposer’s Details
i. Name of Proponent (Mr./ Mrs./ Ms.)
First Name Middle Name Last Name

ii. Father’s Name

iii. Husband’s Name (In case of married female proponent)

iv. Gender v. Marital Status (Married/ Unmarried) vi. Date of Birth (DD/MM/YYYY)
M F / /
vii. Age Proof: [Tick (√) whichever is applicable]
Birth Certificate Matriculation Certificate Driving License Passport PAN
Certificate extract from Service register in the case of Govt. Employees Identity card issued by Defence Department
No.
viii. Aadhaar No. ix. Nationality

x. FOR FEMALE PROPONENT ONLY/ FEMALE SPOUSE (in case of Yugal Suraksha)
Number of Children Are you Pregnant now? Date of last Delivery If pregnant, expected month of delivery
Yes No / / / /
Have you had any abortion or miscarriage or
caesarean section? If so, give details.

2. Spouse Details (In case of Yugal Suraksha policy only)

i. Spouse Name

ii. Spouse Date of Birth (DD/MM/YYYY)

/ /
iii. Spouse Age Proof: [Tick (√) whichever is applicable]
Birth Certificate Matriculation Certificate Driving License Passport PAN
Certificate extract from Service register in the case of Govt. Employees Identity card issued by Defence Department
No.
viii. Aadhaar No. ix. Nationality

Page 1 of 8
3. Proposer’s Address Details
i. Communication Address (If Permanent Address is same as Communication Address please √ in the box ( )

Village Taluka
City District
State Country PIN
ii. Permanent Address

Village Taluka
City District
State Country PIN
4. Proposer’s Contact Details
i. Phone No. with STD Code ii. Mobile No.

iii. E-mail ID (If any)

5. Proposer’s Employment Details

i. Occupation:
Central Govt State Govt PSU Railway Bank Telecom Contractual Joint Venture
Defence Para Military Force Cooperative Society Deemed University/ Educational Institution

Other (Please specify) _____________________________________________________________________________

ii. Name of Organization:

iii. Designation

iv. Date of Entry in Service v. Designation of Immediate Superior

/ /
vi. PAN No. vii. Monthly Income viii. DDO Code
`
ix. Office Address

Village Taluka
City District
State Country PIN
x. Office Phone No. with STD Code xi. Official E-mail ID (If any)

xii. Qualification
Post Graduate Graduate Diploma Se. Sec. Education High School Middle Class Primary Education

Illiterate Other (furnish detail)

6 . Particulars of beneficiary, if policy is proposed to be taken under Married Women Property Act 1874 . (Nomination in such cases not allowed)
Give details of beneficiary(ies) (maximum three) like Beneficiary Name, his/ their Date of Birth, Relationship, whether minor or not, %age of their
share (if more than one beneficiaries) on a separate page

6 A. Particulars of trustee, if policy is proposed to be taken under Married Women Property Act 1874 . (Nomination in such cases not allowed)
Give details of Trust like Individual or Corporation, Name of Trust, Name of Trustee (only in case of Individual Trust), Trustee Relationship,
Communication address, Trustee Phone No. and E-mail ID (if any) on a separate page.

7. Nomination Details (refer Section 39 of Insurance act 1938) (Not applicable in case of policy under MWPA 1874)
a. State particulars of the nominees (not more than three Nominees)

i. Sole/ First Nominee Details- (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

Relationship: Brother Sister Son Daughter Mother Father Spouse

Father-in-law Mother-in-law Others

Page 2 of 8
 Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN
Phone No. E-mail ID (If any)

ii. Second Nominee Details- (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

Relationship: Brother Sister Son Daughter Mother Father Spouse

Father-in-law Mother-in-law Others

Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN
Phone No. E-mail ID (If any)

iii. Third Nominee Details- (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

Relationship: Brother Sister Son Daughter Mother Father Spouse

Father-in-law Mother-in-law Others

Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN
Phone No. E-mail ID (If any)

b. Appointee Details (If nominee is minor)

First Name Middle Name Last Name

Relationship: Gender: M F

Date of Birth: / / Age: Years

Page 3 of 8
 Communication Address

Village Taluka
City District
State Country PIN
Phone No. E-mail ID (If any)

8. Additional Policy(ies) Details

i. Particulars of other PLI/ RPLI policies already held, if any:
Policy No. Type Sum Assured (in `) Maturity Date
1.
2.
3.
4.
5.
6.
Total: (in `)
ii. Particulars of life insurance / health & non life insurance policies of other companies already held, if any:
Policy No. Type Insurer Sum Assured (in `) Maturity Date
1.
2.
3.
4.
5.
6.
Total: (in `)
9. Coverage Details
i. Premium Ceasing Age/
Age at Maturity ii. Policy Term iii. Sum Assured
Years Years ` / -
10. Premium Details (Service/Sales Tax, if any, will be extra)
i. Premium ii. Initial Premium Payment Mode iii. Subsequent Premium Payment Mode
` / -
(Cash/ Cheque/ Credit Card/ Debit Card/ Salary)
iv. Premium Payment Frequency:
Monthly Quarterly Half Yearly Yearly

11. Proponent’s Health Information

a. Are you and your spouse in sound health at present? Yes No (Spouse information in case of YS policy)

b. Have you and/ or your spouse (spouse in case proposal is of Yugal Suraksha) ever suffered/ suffering from any of the following?
(Say Yes or No)
Proponent Spouse (if Yugal Suraksha)
(i) Tuberculosis, Asthma, Bronchitis, Blood : Yes No Yes No
Spitting, or other respiratory disorders
(ii) Cancer, Tumor, Cysts or any other growth : Yes No Yes No
(iii) Paralysis : Yes No Yes No
(iv) Insanity : Yes No Yes No
(v) Any disease of heart and lungs, chest pain, : Yes No Yes No
palpitation, rheumatic fever, heart murmur,
heart attack, shortness of breath, or any other
Heart related disorders
(vi) Kidney disease prostrate, hydrocele and : Yes No Yes No
urinary system
(vii) Any disease of brain, depression, mental/ : Yes No Yes No
psychiatric ailment, multiple sclerosis, stroke,
nervous system, stroke, parkinsonism

Page 4 of 8
 (viii) HIV Positive/ AIDS or any other sexually : Yes No Yes No
transmitted diseases
(ix) Hepatitis-B or C or A : Yes No Yes No
(x) Epilepsy : Yes No Yes No
(xi) Nervous disorder, Gastritis, Stomach or : Yes No Yes No
duodenal Ulcer, Hernia
(xii) symptoms /ailment relating to liver or : Yes No Yes No
reproductive system
(xiii) Leprosy : Yes No Yes No
(xiv) Any physical deformity or handicap : Yes No Yes No
(xv) Any other serious disease : Yes No Yes No

c. Has any of your family members (Father, Mother, Brothers or Sisters) living or dead suffered from any hereditary or infectious disease
like, Insanity/ Epilepsy/ Gout/ Asthma/ Tuberculosis/ Cancer/ Leprosy etc?

Yes No

If yes, give details: ___________________________________________________________________________________________

d. Have you availed any kind of leave on medical ground or hospitalized during the last 3 years? If so, furnish the following information.
Period of Period of Hospitalization
Kind of leave Ailment Name of Hospital
leave From To
1.
2.
3.
e. Do you have any physical deformity or congenital by birth defects? (Yes/ No) _____________________________________

i. If yes, Type of deformity (Congenital/ Non-Congenital): _________________________________________________

ii. In case of congenital deformity, please state whether it is Blindness/ Deafness/ Dumbness/ Orthopaedic Handicap of One Limb/
Loss of one limb/Midgets/Hunchback ________________________________________________________
iii. In case of non-congenital deformity, please state whether it is Blindness/ Deafness/ Dumbness/ Orthopaedic Handicap of One Limb/ Loss of one
limb ___________________________________________________________________________
iv. In case of congenital/ non-congenital deformity, please state whether it is Orthopaedic Handicap of both Limbs/ Loss of both limbs/ Mentally
retarded having mental age of 14 or above/ Weakness or deformity/ Paralysis due to Polio/ Any other deformity of non-neurological origin
______________________________________________________________________________
f. Particulars of the family doctor, if any:__________________________________________________________

12. Additional Health Information (Required in case of Sum Assured/ Aggregate Sum Assured is above `20 lakh)
Proponent Spouse (if Yugal Suraksha)
(i) Are you currently undergoing/have : Yes No Yes No
undergone any tests, investigations,
awaiting results of any tests, investigation
or have you ever been advised to undergo
any tests, investigations or surgery or
been hospitalised for general check-up,
observations, treatment or surgery
(ii) Diabetes/ High Blood Sugar : Yes No Yes No
(iii) High/ Low Blood Pressure : Yes No Yes No
(iv) Have you ever been referred to an :
Oncologist or cancer hospital for any
investigation or treatment
(v) Did you have any ailment/injury/accident : Yes No Yes No
requiring treatment//medication for more
than a week
(vi) Have you ever suffered Thyroid dis- order : Yes No Yes No
or any other disease or disorder of the
endocrine system
(vii) Ave you undergone/have been : Yes No Yes No
recommended to undergo Angioplasty ,
bypass surgery, brain surgery, Heart valve
surgery Aorta surgery or organ transplant

Page 5 of 8
 (viii) Have you ever suffered disorders of eye, : Yes No Yes No
ear, nose, throat, including defective sight
speech or hearing & discharge from ears
(ix) Have you ever suffered Anaemia, blood or : Yes No Yes No
blood related disorders
(x) Have you ever suffered musculoskeletal : Yes No Yes No
disorders such as arthritis, recurrent back
pain, slipped disc or any other disorder of
spine, joints, limbs or leprosy

12.1 Additional Health Information for Female Proponent (In case of Sum Assured or Aggregate Sum Assured exceeding `20 lakh)

i. Have you ever have any abortion, miscarriage or ectopic pregnancy : Yes No
ii. Have you ever undergone any gynaecological investigations, internal : Yes No
checkups, breast checkups such as mammogram or biopsy
iii. Have you ever consulted a Doctor because of an irregularity at the breast, : Yes No
vegina, uterus, ovary, fallopian tubes, menstruation, birth delivery,
complications during pregnancy or child delivery or a sexually transmitted
diseases?

13. Personal habits of the proponent impacting health (Required in case of Sum Assured/ Aggregate Sum Assured is above `20 lakh)
If Yes, Whether Frequently or Occasionally
(i) Do you Smoke/ Consume Tobacco? : Yes No Frequently Occasionally
(ii) Do you Consume Alcohol? : Yes No Frequently Occasionally
(iii) Do you Consume Drugs? : Yes No Frequently Occasionally
(iv) Do you have any habits, which can : Yes No If yes, furnish details_____________
adversely impact your health?

14. Suitability Analysis(Required in case of Sum Assured/ Aggregate Sum Assured is above `20 lakh)

i. Affordable Contribution
Current Next Next Next Next Next
YEAR Last Year 25-30 Yrs
Year 5-10 Yrs 10-15 Yrs 15-20 Yrs 20-25 Yrs
a. Yearly
b. Monthly

ii. Income/ Expenditure – Current and Projected (in `)

Current Next Next Next Next Next
YEAR Last Year 25-30 Yrs
Year 5-10 Yrs 10-15 Yrs 15-20 Yrs 20-25 Yrs
a. Income
b. Expenditure

iii. Financial Details (in `)

a.Value of Savings and Assets
b.Details

iv. Family/ Dependent Details

Particulars 1 2 3 4
a. Names of family members/ dependents
b .Male/ Female
c. Relationship
d. Date of Birth
e. Occupation
f. Whether financially dependent

15. Declaration of Proponent/ Spouse (Spouse signature is required in case of Yugal Suraksha Policy)

(A) I/ We do hereby declare that (a) no proposal of insurance on my/ our life/ lives has ever been adversely treated by any i nsurance
company (b) the foregoing statements made are true to the best of my/ our knowledge and belief (c) in case it is found that I/ we have
wilfully made any untrue statement or have concealed any relevant circumstances then all the premia which shall have been paid by
me/ us, shall be forfeited and this contract rendered absolutely null and void (d) I/ We understand that my/ our life/ lives shall be
insured from the date my proposal is accepted (e) I/ We have gone through the terms and conditions for insurance with PLI, a copy of
which has been given to me/ us and explained to me/ us in my language. I/ We hereby agree to abide by them.

Page 6 of 8
*I further declare that:
a) The contents of surrender table and instructions for admissibility of surrender value have been explained to me before taking
policy and I abide by the same.
b) Surrender of a policy is not admissible before completion of thirty six months of the policy and the amount deposited shall be
forfeited if I surrender the policy within thirty six months.
c) On surrender, the policy shall attract proportionate bonus on reduced sum assured up to the date for which premium has been
paid. However, no bonus shall be payable before completion of 5 years of the policy.
d) The discontinued policy shall not attract bonus with effect from the date from which the premium is discontinued.
e) The reduced sum assured shall be calculated by multiplying the sum assured with the number of instalments paid and dividing
the same with the total number of premiums to be paid.
f) The surrender value shall be calculated by multiplying the sum of reduced sum assured plus the proportionate bonus, if any,
with the surrender factor as applicable on the attained age on the date of surrender of the policy.
*Surrender is applicable for WLA, CWA, EA & YS policies.

(B) I/We_________________________________________Son /wife /daughter of ____________________________________

aged __________years & ___________________________________________________________ Son /wife /daughter of
_____________________________________________ aged _____________ years do hereby declare that:
I/We am/are not suffering from Hypertension & Diabetes and not taking any treatment for Hypertension & Diabetes.
OR
I/We have been suffering from Diabetes/Hypertension for the Last _____ years but with proper medical advice & medication
it is with in control and no complication has surfaced so far posing any threat to my life.

( C) I/ We hereby agree to pay the fee of `_______________________________________________________________________

(per individual) for the medical examination if our proposal is not accepted.

Spouse’s Signature:________________________________ Proponent’s Signature:___________________________

Dated: The ________________Day of ____________________ 20____

16. Certificate of Immediate Superior

Certified that ____________________________________________________ is a permanent/ temporary employee in

____________________________________________________________ and information
furnished against column No. 1 to 5 & 11 (d) of this proposal form is correct as per his/ her service records.

Date : __________________ Signature: _____________________

Place: __________________ Name : _____________________

Designation/Seal: _____________________
17. To be filled in by DO/ FO (PLI)/ Agent/ Sales Force
i. In case Sum Assured/ Aggregate Sum Assured is less than/ equal to `20 lakh.

I ____________________________________ Agent Code No./ ID ______________________________ certify that the information

in the proposal form has been furnished by the proponent and it has been signed by him/ his thumb impression has been taken in my
presence. All columns have been completed and are correct and no question is left un-answered. The proposal is recommended for
acceptance.

Date: _________________ Agent’s Signature: ________________________________________

ii. In case Sum Assured/ Aggregate Sum Assured is above `20 lakh.
1. Life Stage Childhood/ Young unmarried/ Young married/ Young married
with children/ married with older children/ post-family or pre-
retirement/ retirement
2. Protection needs Life & Health/ Savings and Investment/ Pension
3. Appetite for risk Low/ Medium/ High
4. Policy recommended, including name of insurer
5. Details of commitment for the current and future years
6. Whether all risk elements and details of charges to be incurred
and all other obligations have been explained?
7. Why do you think this policy is most suited for the proposer?
8. Whether product proposed is:
i. Based on need
ii. Based on demand
iii. Based on Agent’s recommendation

Page 7 of 8
iii. Details to be entered in all cases by Agent/DO/FO (PLI)/Sales Person/ Broker.

Policy Type:____________ Sum Assured:_____________ Age at entry:_____________ Premium rate:`____________

Receipt LI-7(a) No. :_______ Date:_____/______/20______ Amount Collected from Proponent:`_______________________
Name of Medical Officer:_____________________________ Code No. of Medical Officer:____________________________
Post Office where payment is being deposited: _______________________________________________________

DO/FO (PLI)/Agent/ Sales person’s / Broker’s Certification:

I/We hereby certify that I/we believe that the product(s) recommended by me/us above is suitable for the proposer, based on the
information submitted by him/her, as recorded above. I/We declare that the policy recommended has been fully explained to the
proposer, including about the terms and conditions, exclusions, premium commitments and various charges, as applicable.

Dated: _____________________ (Signature of Agent/DO/FO (PLI)/Sales Person/ Broker)

Proposer’s Acknowledgement

The above recommendation is based on the information provided by me. I have been explained about the features of the product
and I believe, it would be suitable for me based on my insurance needs and financial objectives.

Dated: _____________________ (Signature/Thumb Impression of Proposer)

18. Medical Examiner’s Certificate:

Certified that I have carefully examined Shri/ Smt. ___________________________________________ the proponent,

and Shri/ Smt. _____________________________________________________________________ the spouse,

whose signature is/ are given below today the _________________ Day of _____________________ 20_________.

On careful examination of the proponent and after going through the information furnished by him/ her under column 12
and reports of prescribed medical tests, I find the proponent/ spouse to be medically fit. He/ She/ They does/ do not
suffer from any terminal or other serious health hazard which would be risk to his/ her/ their life. I recommend
acceptance of his/ her/ their proposal of Postal Life Insurance policy.
OR
The proponent and spouse is/ are medically unfit. I do not recommend acceptance of his/ her/ their proposal for Postal
Life Insurance policy.

Signature of Proponent:_____________________ Signature of Medical Examiner: _________________

Name: _____________________________________
Seal : _____________________________________
Date : _____________________________________
Signature of Spouse:_______________________ ID/ Code : __________________________________
(In case of Yugal Suraksha)

NOTE FOR MEDICAL OFFICER

a) If the proponent is overweight or has doubtful family history an electrocardiogram and a report on the scanning of the chest would be
required.
b) If the proponent is underweight and has family history of TB, an X-Ray of the chest would be required.
c) Expense of the above mentioned tests will have to be borne by the proponent.

Tests required in case Sum Assured or Aggregate Sum Assured is more than `20 lakh
d) Supplementary Bio- Chemical Tests [SBT -13]
1. Fasting Blood Sugar- Method________ , 2.Total Cholesterol, 3. High Density, Lipid [HDL], 4.Low Density Lipid [LDL] 5. S Triglycerides,
6 S Creatinine,7. Blood Urea Nitrogen - a. Albumin, b Globulin, 8. © AG Ratio – S Bilirubin- a .Direct, b. Indirect c Total 9. SGOT [AST], 10.
GGTP [ALT] 11. S Alkaline Phosphate, 12 Hbs AG [Australia antigen] & 13. Elisa for HIV [Method________].

e. Following tests are required to be conducted:

Age up to 35 years- ECG, Routine Urine Analysis, SBT 13, Hb %
Age between 36 to 45 ECG, Routine Urine Analysis, SBT 13, Hb %. CTMT, Hemogram
Age between 46 to 55 years ECG, Routine Urine Analysis, SBT 13, Hb %. CTMT, Hemogram, Hb Alc
Age of 56 years & above ECG, Routine Urine Analysis, SBT 13, Hb %. CTMT, Hemogram, Hb Alc
[Policy Revival cases] X ray of chest

Page 8 of 8