Swetha Form
Swetha Form
PHOTO OF THE
LIFE TO BE
IILIC
'1 ~~~
urc INSUlt.lNCC COflPORATION or INOll
FORM NO. 300 (Rev 2021)
PROPOSAL FOR INSURANCE ON OWN LIFE
(Not be used for Insurance on the llves of minors)
ASSURED
To be filled by agent:
1. D.O./CLIA Code No/ Mentor code & Mobile number :
2. Agent's/Specified Person's/DSE's/Sup Agent's Name ,Code No & Mobile number:
3. Licence No:
4. Date of Expiry:
For Office Use Only :
Inward no: Date
Proposal no : Amt of Deposit : B.O.C No: Date:
I.Personal Details
1 Name Prefix Middle Name Last Name
Mr./Mrs./Ms/Mx.: F ~ JJ--IW[THA .:re~EA6JNA
2 Father's Full name
3 Mother's Full Name
4 Gender Male / Female / Third Gender . Ft?v1AL E
5 Marital Status \JN N &RR 1m
6
7
Spouse's Full name
Date of Birth
-
f '°' / D? I 1~'11--
8 Age** Years
•• Depending upon the plan conditions, Age last birthday/Age nearer birthday shall be applied for the calculaton of premium
9 Place/ City of Birth f.4D.~PETt
10 Nature of Age Proof
Submitted
11 Nationality HfNVV
12 Citizenship
13 Correspondence Address ~lttl\~ fi.~ fl Fl hW
House No.
City/ Town/ Village
District & State
Country
PIN Code
Tel. No. with STD Code
14 Permanent Address
House No.
City/ Town/ Village I t MKVR.
District & State ~\ 'OtJ t<.\J R . K ttR.N ftTA-K A
Country 1:t\l· u1 A ,
PIN Code ~-;f:l ' 0 ,._,
Tel. No. with STD Code
1
15 Residential status Resident Indian/ Non Resident Indian/ Foreign National of Indian Origin/
Overseas Citizen of India
16 Address outside India ( Applicable only for NRI/FNIO/ OCI)
House No.
City/ Town/ Villaoe
District & State
Country
PIN Code
II KYC& PMLA
1 Are you Income Tax Y/~y
Assessee
2 PAN Number •Cn'f>VP~I \q~_s
3 ID details( to be answered only if PAN card copy is not submitted)
• In case of Aadhaar only last four dioits is to be oiven as Id number
Proof of Identity
ID number • c, ~ lCl' \) ;f- Lt
Expiry date of id
-
4 Address Proof Submitted
5 Are You Registered under
GST, if yes give GSTIN :
6 C KYC number ( Central
KYC Registry)
Ill Occupation / -
1 Educational qualification /?/? rJi P / ,!.:/3/ 0_/ / P1 /'l,j;,(7 P.k,//1a
2
3
Present Occupation
Source of Income
/ e / } rn
JCI L
/ p .fi;./
~
/1
-✓ J
4 Name of the present
employer
,1/Vu.b e
5 Exact Nature of duties
6 Length of service
7 Annual Income I/ TPJJ
8 To be answered if employed in the Armed Forces
a Wing to which you belong
b Rank therein .
C Date of last Medical
~xamination
d Medical category after
medical examination
e Were you ever below A-1
category? If so, when?
IV Others
1 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? If yes , give details and submit
respective questionnaire .
·2 Have you ever been or are currently being investigated, charge
sheeted, prosecuted or convicted or having pending charges in
respect of any criminal/civil offences in any court of law in India
or abroad ? If yes, give details.
3 Are you a Politically Exposed Person OR are you a family
member or close relative of Politically Exposed Person?
[As per RBI guidelines PEPs are the individuals who are or have
been entrusted with prominent public functions in a foreign
country.]
2
V Existing Insurance: Please give details of your previous insurance taken from UC as well as from other
insurers (including policies surrendered / lapsed during last 3 years)
Note: 1. If space is not sufficient for all existing policies, please use separate sheet in the same format . it must
be duly signed by the life to be assured
2. Corporation normally 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 Policy Number
~ Name of the Insurer/
Division/ Branch
3 Plan and Term
4 Sum assured
5 Term Rider Sum
Assured
6 Cl Rider Sum Assured
7 AB/ ADDB Sum
assured
8 Date of Commencement
9 Date of Revival
10 Whether accepted at
ordinary rate, if not give
details
11 Medical/ Non medical -
12 Whether lnforce
13" If not, Date of FUP/
Date of surrender
14 Has a proposal ( or an application for revival of a policy) on your life made to Yes/No Details
any office of the Corporation or to any other insurer ever been
a Withdrawn, Deferred, Dropped or Declined?, if yes give details.
b Accepted with extra Premium or Lien?, if yes give details.
C Accepted on terms other than those proposed?, if yes give details.
d Have you during the past one year returned any policy of the Corporation as
the same was not acceptable to you?, if yes Qive details.
VI Details of Nominee and appointee (It is in the interest of the life to be assured to avail the facility of nomination)
Name and address of % Age Relationship If Nominee is Relationship Appointee's
Nominee share with the life to minor to the signature as a
be assured appointee's full nominee token of
name, age and consent
address
Id proof of Nominee/
Appointee
Id Number
Ill Please Tick the Riders which you want to avail along with the base plan as per the Plan conditions
IV Plan, Sum assured and Rider selected by the Life to be assured( Riders are subject to availability
under the selected plan)
a Plan, Term Sum Mode of Premium Term Rider Critical Accident If policy is to
& Premium Proposed Payment Sum illness sum benefit sum be dated back
paying Term (Basic Sum (Yly/Hly/Qly/ SSS proposed proposed (if proposed (if indicate date
Assured) /NACH/ Single) (if opted) opted) opted)
J{we/u,- 1000 oo
~ ly
b Applicable to Police Personnel if LIC's Accident Benefit Rider/ LIC's Accidental
Death And Disability Benefit Rider is opted for :
i. Whether you are engaged in police duty in any police organization other Y/W
than paramilitary force?lf "Yes",
ii. Whether you wish to avail the AB/AD& DB rider while on police duty? Y/~
C For SSS Policies :
i. Paying authority code and Dept No
ii. BadQe or SR No
V. To be answered only if proposing for "LIC's Premium Waiver Benefit Rider " in case of insurance on
Minor Life
Premium Waiver Benefit under this rider shall be equal to waiver of premiums payable under the Base Policy falling
due on and after the date of death of Proposer till the expiry of rider term.
However, premiums in respect of any riders, if opted for, other than this rider under the base policy shall not be waived
and continue to be paid as per respective rider conditions.
Further if premium paying term of the base policy exceeds the rider term all the premiums due under the base policy
from the date of expiry of "LIC's Premium Waiver Benefit Rider" shall be payable by the Life Assured as per the
terms and conditions of the Base policy.
VI. To be answered only If proposing under "LIC's Aadhaar Stambh" or" LICs Aadhaar Shila"
a. Total existing (excluding the proposal under consideration) sum assured under LIC's Aadhaar
Shila/ LIC's Aadhaar Stambh :
b.
-----
Is your life being proposed simultaneously under the same plan? Yes/No.
If "Yes", give details :
-----
Note: The total Sum Assured under LIC's Aadhaar Stambh or LIC's Aadhaar Shila on an Individual sh Id t
exceed Rs. 3 lakhs. ou no
4
ications and for Jeevan Amar
VII: To be answered only If applicable as per Plan specif
of the following):
a. ~nder which category do you wish to apply? (Tick one
1) Smoke r □
ii) Non- Smoker □
basis of findings of Urine Cotlnlne Test.
Note: Non- smoker rates wlll be offered only on the
( ~)
one of the options for Sum Assured on Death (by ticking
b. Question regarding Death Benefit: Please select
in the appropriate box) depending upon your specific needs:
Option I: "Level Sum Assured", where Sum Assured on
Death shall be an amount equal to Basic Sum
L..._ _ __,
I
Assured and shall remain constant throughout policy term.
,
VIII Simultaneous Proposals YIN/
an application
a Is your life now being proposed for another assurance or
for revival of a policy on your life or any other proposal under
insurer?
consideration in any office of the Corporation or to any other
If yes, give details ,
I
a
Personal Health
Please state exact height ( in ems) and weight ( in Kgs)
( without Height
11.3
j Weight 50
shoes)
b During the last five years did you consult a Medical Practit
ioner for any YIN
g treatment for more than a week ? If ves, give details
ailment reauirin
C Have you ever been admitted to any hospita l or nursing home for YIN
If yes, give
general check up, observation, treatment or operation?
details
d Have you remained absent from place of work on ground
s of health YIN
during the last 5 years? If yes, give details
5
past or have you been
suffered or undergone investigation in the
e Are. you suffering from or have you ever the follow ing ailme nts:
ent for
advised to undergo investigation or treatm Diseases Y/N
Diseases Y/N
t 2. Hype rtens ion, Hypo tension, rheumatic fever,
1. Lungs/ Respiratory Disease I Persisten hless ness, palpitation, any Ill
ng " / pain in chest, breat
cough, asthma, bronchitis, pneumonia, spitti fV disea se of the heart or arter ies?
of blood etc 4. Any disea se of kidney /prostate or urinary
mia, piles ,
3. Peptic ulcer/colitis, jaundice, anae
dysentery, or any other disease of the
/l} system? Al
stomach, liver, spleen, gall bladd er or
pancreas/ digestive disorder ose
6. Hernia/hydrocele, varicocele, fistula, varic
5. Paralysis/epilepsy/ insanity/ tremors, , ,filariasis, gono rrhoe a, syph ilis or any
veins
numbness, double vision, dizzy or fainting tJ other venereal disease?
spells/ head Injury / insomnia/ nervous
or
breakdown I any other disease of the brain
the nervous system ,
cyst/ 8. Any disease of ear, nose, throat or eyes
7. Cancer/leukemia/lymphoma/ tumour I including defective sight or hear ing and ;V
Any other growth/ lumps/ blood disorder N discharge from the ears
/enlarged gland s
1O. Bone/ Joint/ Spine Disease/ Arthritis
9. Endocrine disorders such as Diabetes, fl
ed
Goitre, Thyroid etc or have you ever pass /J
sugar, albumin, pus or blood in urine 12. Chronic infections- Tuberculosis/ pleur
isy I
11. Mental Disorder (Depression/ Anxiety, Leprosy. ;ti
N Skin Disea se/ skin erup tion/
bodily
etc.).
& HIV related cond ition 14. Any Operation, accident or injury/ any 1V
13. Hepatitis or AIDS
N defect or defor mity.
15. Any other disease? below ( If hospitalized ,
in 'e' above is yes, please give details as
f If answer to any of the questions mentioned sal form. )
tigation papers along with the propo
enclose the discharge summary and all inves Still on treatment (Y/N) , If Name and address
Date of Fully recovered of Doctor/ Hospital
Nature of disease I Yes give details of
s Diag nosis (Y/N)
illnes treatment
/
II Personal Habits YIN( If yes, quantity If stopped,
smoked/consumed the
Do you smoke/consume or have you ever consumed and duration since how many
following (a,b,c) months
J,.f
a. Alcoholic drinks
/V
b. Narcotics
c. Any other drugs, If yes, which one
Al
ed/consumed
d. Do you smoke/ consume or have you smok
product includes but not limited
tobacco in any form (Toba
beed
cco
is; chew able tobac co like Gutkha, M
to cigars, cigarettes, (in sticks
60 mont hs.
flavored paan masala, etc.) in the past
/packets/ sach ets/day or gms /day)
health?
Ill What has been our usual state of
IV Family details
1 Have your parents I spouse / Partner/ children and/o
r any of your
or died of heart disea se, stroke, high
relations ever suffered from
blood pressure, diabe tes mellitus, canc er, kidney disease or any
gious diseases such as
/V
hereditary disorders, Insanity, or any conta
If yes, please specify
tuberculosis ,hepatitis, AIDS I HIV etc.?
a. Nam e of the disea se
b. Relationship with the life to be assured and
C. date I year of death
2 Family History
I Living I Dead
6
A eat death Year/cause of death
State of health
Father
Mother
Brothers
Living
Dead
Sisters
Living
Dead
So use
Children
Living
Dead
d
Signature or Thumb impression of the life to be assure
Signature of Witness
Name JJfi.»! e&_
Occupation ----
I (!,,Curi. / eo.._cl
Address:..___ _ _ _ __
nt from that of the
case form Is filled up/signed In a language differe
1. Declaration bv the person filling In the fonn {In dlsablllty (PWD) where he/she Is not able to fill the propo sal
with
Proposal Fonn or In case the proposer Is person
form himself/ herself.)
rs given
ns to the proposer and I have truthfully recorded the answe
"I hereby declare that I have fully explained the above questio sion/ signature as below after fully understanding the contents
by the proposer and proposer has affixed the thumb impres ,hf:
~
thereof."
Name of the Declarant: J b er/k>. Signat ure: €Q- ::-
8
r "lereby .d%lare that I have fully explained the above questions and contents
of the proposal form to the proposer il
"/u language, and that the propose, has affixed the thumb impression above after fully
understanding the contents
ther f."
Signature: c/1we.JJ¾,
Name of the Declarant: • 2PAwe_&.t,
Address of the Declarant: - - - - - - - -