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Spouse’s Proponent’s
recent recent
DEPARTMENT OF POSTS passport size passport size
PROPOSAL FORM FOR POSTAL LIFE INSURANCE photograph photograph
All entries should be filled in CAPITAL letter:
FOR OFFICIAL USE ONLY
Name of the Development Officer/ FO/ Agent/ Postal Proposal No.
Employee (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 `
Post Office at which deposited
Agent Code
ACG-67 Receipt No. and Date
Policy No.
Proposal Date (DD/MM/YYYY) Date of Declaration (DD/MM/YYYY)
/ / / /
Product/ Policy Type WLA CWLA 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. Nationality
ix. FOR FEMALE PROPONENT ONLY/ FEMALE SPOUSE (in case of Yugal Suraksha)
Are you Pregnant
Number of Children now? Date of last Delivery Date of Last Menstruation
Yes No / / / /
If pregnant, expected month of delivery
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.
iv. Spouse Nationality
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
Page 1 of 5
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. HUF Details (If applied under HUF)
Give particulars of HUF like Name of Karta, PAN No. of Karta, Communication Address, Member’s/ Coparceners
Names, Relationship with Karta, Age of Member’s/ Coparceners Names with names of two (2) witnesses with their
signature and addresses on a separate page.
7 A. 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.
7 B. 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.
8. 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
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
Page 2 of 5
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
Communication Address
Village Taluka
City District
State Country PIN
Phone No. E-mail ID (If any)
9. Additional Policy 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 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 `)
10. Coverage Details
i. Premium Ceasing Age/
Age at Maturity ii. Policy Term iii. Sum Assured
Years Years ` / -
11. Premium Details
i. Premium ii. Initial Premium Payment Mode iii. Subsequent Premium Payment Mode
` / -
(Cash/ Cheque/ Credit Card/ Debit Card/ Salary)
Page 3 of 5
iv. Premium Payment Frequency:
Monthly Quarterly Half Yearly Yearly
12. 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 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 : Yes No Yes No
(ii) Cancer : Yes No Yes No
(iii) Paralysis : Yes No Yes No
(iv) Insanity : Yes No Yes No
(v) Any disease of heart and lungs : Yes No Yes No
(vi) Kidney disease : Yes No Yes No
(vii) Any disease of brain : Yes No Yes No
(viii) HIV Positive : Yes No Yes No
(ix) Hepatitis-B : Yes No Yes No
(x) Epilepsy : Yes No Yes No
(xi) Nervous disorder : Yes No Yes No
(xii) Liver : Yes No Yes No
(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.
Kind of leave Period of Ailment Name of Hospital Period of Hospitalization
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/ Orthopedic 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/ Orthopedic Handicap of One Limb/
Loss of one limb ____________________________________________________________________________________________
iv. In case of congenital/ non-congenital deformity, please state whether it is Orthopedic 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:__________________________________________________________________________
13. Declaration of Proponent/ Spouse
(A) I/ We do hereby declare that (a) no proposal of insurance on my/ our life/ lives has ever been adversely treated by any insurance
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.
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.
(B) I/ We hereby agree to pay the fee of `_______________________(per individual) for the medical examination if our proposal is
not accepted.
Proponent’s Signature:_______________________
Spouse’s Signature:_______________________
Dated: The ________________Day of ____________________ 20____
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14. Certificate of Immediate Superior
Certified that ____________________________________________________ is a permanent/ temporary employee in
______________________________________________________________ and information furnished against column No. 1 to 5 of
this proposal form is correct as per his/ her service records.
Date : __________________ Signature: ________________________
Place: __________________ Name : _______________________
Designation/Seal: __________________
15. To be filled in by DO/ FO (PLI)/ Agent
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: __________________________
16. 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, 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.
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