LATEST

FORM NO. 300 (Rev 2024) COLOUR PHOTO

PROPOSAL FOR INSURANCE ON OWN LIFE OF THE LIFE TO
(Not be used for insurance on the lives of minors) BE ASSURED
Division:
Branch Office:
INSTRUCTIONS TO FILL THE PROPOSAL FORM
1. This form is to be completed in BLOCK LETTERS by the Life to be assured.
2. Please read all the questions carefully and fill up the details truthfully.
3. If the Life to be assured signs this proposal in vernacular or puts his/her thumb impression upon it, then the respective declaration
must be completed.
4. Answers should be legible. Questions should be answered in ‘Yes’ or ‘No’. (Strokes / dots / dashes / leaving the questions
unanswered will not be accepted). Details need to be provided in case of affirmative answers.
5. The Life to be assured must countersign any cancellation and alterations made in this form. White ink must not be used.

To be filled by Agent/ Intermediary SAROJ GUPTA AGENCY CODE 90639411

1. D.O./CLIA/Chief Organizer/ Intermediary Agency Code No& Mobile number : ZM’S .CLUB MEMBER
2. Agent’s/Specified Person’s/DSA’s/Sup Agent’s Name, Code No & Mobile number: L.I.C. OF INDIA. C.B.O. -10
3. KOLKATA 700001
4. License No/Registration No: 4. Date of Expiry(DD/MM/YYYY):
For Office Inward no : Date(DD/MM/YYYY):Proposal no : B.O.C No: Date(DD/MM/YYYY) :
Use Only Amt of Deposit (Rs) :
Section -I:Details of the Life to be assured

I Personal Details
1 Customer ID
2 C KYC 40093837597696
number
3 ABHA NILL
number
4 Name Prefix First Name Middle Name Last Name
NAVYA KHANDELWAL
5 Father’s Full First Name Middle Name Last Name
name SANDEEP KHANDELWAL
6 Mother’s First Name Middle Name Last Name
Full name PRABHA KHANDELWAL
7 Gender FEMALE
8 Marital Status UNMARRIED
9 a. Date of _01___/___11___/ Age . Age proof submitted PAN CARD
Birth ___2000_____ 24
(DD/MM/ (Yrs
YYYY) )
1 Proof of Id Number (In case of 9561
0 Identity: AADHAR CARD Aadhar only last four
digits) 9561
1 Permanent Address as per above Proof of Identity AADHAR CARD
1
House No./Building Name / Street AMBIKA GARDENS, FLAT NO-5D, 23 RAJA SANTOSH ROAD
Town/ Village / Taluka ALIPORE 700027
City/ District KOLKATA
State &Country WEST BENGAL
PIN Code 700027
1 Correspondence / Current Address if different from above ( Proof to be submitted)
2
House No./ Building Name / Street N.A
Town/ Village / Taluka N.A

1
 City/District N.A
State &Country N.A
PIN Code N.A
1 Contact details . AMBIKA MOBILE WHATSAP MAIL,NAVYA.KHANDELWAL09@GMAIL.C
3 GARDEN , NO.833605893 P NO OM
FLAT NO 5D ,23 RAJA SANTOSH 0 833605893
ROAD.ALIPORE.KOLKATA 0
700027
1 Nationality INDIAN
4
1 Residential status Resident Indian / Non Resident Indian*/Foreign National of Indian Origin*
5 INDIAN *NRI Questionnaire mandatory
INDIAN

1 Is your country of Tax Residency outside India ? NO Yes / No(If yes, fill the Self Certification Form
6 NO
1 Are you an Income Tax Assessee Yes
7
1 Permanent Account Number (PAN) IDPPK9022N
8
1 If Registered under GST, please give GSTIN NO
9
II Educational Qualification and Occupation B.TECH IN ELECTRONIC AND COMPUTER SCIENCE.SERVICE
1 Educational qualification B.TECH AND SOFTWARE ENGI NEER
2 Present Occupation / Source of Income SERVICE AND SALARY
3 Name of the present employer HSBC TECHNOLOGY INDIA
PUNE
4 Exact Nature of duties (please specify if engaged in police duty) SOFTWARE ENGINEER
5 Length of service JULY 2022
6 Annual Income (Rs.) 90 ANUM0000PER
7 Are you employed in the Armed Forces (If Yes, submit relevant questionnaire) No
II Others
I
1 Is your occupation associated with any specific hazard or do you take part in hazardous activities or have hobbies NO
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 NO
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 NO
Person?(As per RBI guidelines PEPs are the individuals who are or have been entrusted with prominent public
functions by a foreign country).
I Existing Insurance: Please give details of your previous insurance taken from LIC as well as from other insurers (including
V 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 fresh proposal for insurance where a policy has been lapsed or
converted into paid up policy within the last 3 years.
1 Policy Number
2 Name of the Insurer/
Division/ Branch
3 Plan and Term

2
 AS PER LSIT
4 Sum assured (Rs.) ENCLOSED

5 Term Rider Sum

Assured (Rs.)
6 CI Rider Sum Assured
(Rs.)
7 AB/ ADDB Sum
assured (Rs.)
8 Date of
Commencement
(DD/MM/YYYY)
9 Date of Revival
(DD/MM/YYYY)
AS PER LIST ENCLOSED
1 Whether accepted at
0 ordinary rate, if not
give details
1 Medical/ Non medical
1
1 Whether Inforce
2 (Yes/No)
1 If not , Date of FUP/
3 Date of surrender
(DD/MM/YYYY)
1 Has a proposal ( or an application for revival of a policy) on your life made to
4 any office of the Corporation or to any other Insurer ever been Accepted with NO
a extra or modified terms, Withdrawn, Deferred, Dropped or Declined?, if yes
give proposal number& branch / policy number / Name of Insurer

b Have you during the past one year returned any policy of the Corporation as N.A
the same was not acceptable to you?, if yes give policy number.

V Details of Nominee and Appointee (It is in the interest of the Life to be assured to avail the facility of nomination.The
nomination can be Single or Multiple. Please give % share in case of multiple nomination)
Name of the % DOB Age Relationshi Mobile Email ID Address of
Nominee share (DD/MM/ (Yrs p with the No. the
YYYY) ) Life to be Nominee
assured
SANDEEP 11/09/1973 51 FATHER 983085335 SAME AS
100 4 SANDEEP.KHANDELWAL1 PROPOSE
KHANDELWA % 0@ R
L
GMAIL.COM

Nominee’s Bank Details:

Bank name SHREE ARCADE 1ST Bank Account no. IFSC code
FLOOR 2 JOGENDRA KAVIRAJ
ROW
KOLKATA700007 02191000021342 HDFC0000219
Appointee’s details ( Applicable in case of Minor Nominee) NO

Name of DOB Age Relationship Mobile Email ID Address of Appointee’s signature or

Appointee (DD/ (yrs) to Nominee no. Appointee thumb impression as a token
M of consent
M/YY
3
 YY)
N.A N.A N.A N. N.A N.A N.A N.A

V Bank Details
I

THE HONGKONG AND SHANGHAI BANKING CORPORATION LTD IN0056 - PUNE ACCOUNT NO
106383599OO6
UAN 101863945120 .IFSC CODE HSBC0411O002

b) Your Account No :_106383599006 UAN_1018639451_____________________

c) IFS Code:_HSBC0411002____________________________ d) Name of your bank:THE HONGKONG AND
SANGHAI BANKING CORPORATION LTD___________________________ {Attach a cancelled cheque leaf (along
with copy of bank passbook if name is not printed on the cheque leaf)}

Section – II: Proposed Plan Details

I Objective of Insurance Saving and Risk Cover

II Whether proposal is under (please tick Individual life
relevant options)
** Note:If proposal is not under individual life , please submit relevant questionnaire / annexure/supporting documents
along with the proposal form
III Details of Plan and Ridersopted. ( Riders are subject to availability under the selected plan). Depending on plan selected,
a Addendum for plan specific details to be completed
733 Tick the opted Rider Sum
Plan Riders opted Rider Proposed (Rs)
13 LIC’s New Term Assurance NO N.A
Term
Rider
10 LIC’s New Critical Illness N0 N.A
Premium Paying Term
Benefit Rider
Sum Proposed (Basic Sum 4500000 LIC’s Premium Waiver NO N.A
Assured) Rs BenefitRider
Mode of Premium MONTHLY LIC’s Accident Benefit Rider NO N.A
Payment (Yly/Hly/Qly/SSS ECS ======== OR===========
WITH 4500000
/NACH/ Single) LIC’s Accidental Death and
Disability Benefit Rider
Date if policy is to be dated NO If engaged in police duty do you wish to avail
back (DD/MM/YYYY) AB/AD&DB Rider while on police duty N.A
b For SSS Policies : i) Paying Authority code and Dept No ii) N.A
Badge or SR No
c Do you wish to avail “Option to take Maturity Benefit in Instalments”: NO
Do you wish to avail “Option to take Death Benefit In Instalments” : NO
If ‘Yes’, Kindly fill the addendum which forms a part of the proposal form.
IV. 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.
Do you agree with the above NO
Note: Proposal shall be considered for LIC’s Premium Waiver Benefit Rider only, if your answer to the above question is “NO
V Simultaneous Proposals
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a Is your life now being proposed for another assurance or an application for NO
revival of a policy on your life under consideration in any office of the
Corporation or with any other Insurer?
If yes, give Proposal no. / Policy no. and Branch Code
b Whether proposed simultaneously on the life of spouse and children? If yes, NO
give Proposal no. and Branch Code
VIa Do you wish to avail the physical policy document? NO
b Please give EIA no. (e-Insurance Account) If available. NO

Section- III: Personal and family details of health / habits

I Personal Health
a Please state exact height and weight ( without shoes) Height( in cms) 163 Weight( in Kgs) 54
b During the last five years did you consult a Medical Practitioner for any ailment requiring NO
treatment for more than a week ? If yes, give details
c Have you ever been admitted to any hospital or nursing home for general check up, NO
observation, treatment, accident, injury or operation? If yes, give details
d Have you remained absent from place of work on grounds of health during the last 5 years? NO
If yes, give details
e 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:
Diseases Y/N Diseases Y/N
1. Lungs/ Respiratory Disease / Persistent cough, NO 2. Peptic ulcer/colitis, Jaundice, Hepatitis, NO
asthma, bronchitis, pneumonia, anaemia, piles, dysentery, or any other disease of
Tuberculosis/, pleurisy / spitting of blood/Covid 19etc the stomach, liver, spleen, gall bladder or
pancreas/ digestive disorder
3.Hypertension, Hypotension, rheumatic fever, pain in NO 4. Endocrine disorders such as Diabetes, Goitre, NO
chest, breathlessness, palpitation, any disease of the Thyroid etc or have you ever passed sugar,
heart or arteries? albumin, pus or blood in urine
5. Any disease of kidney /prostate or urinary system? NO 6. Bone / Joint/ Spine Disease/ Arthritis / varicose NO
veins /any bodily defect or deformity
7. Any disease of ear, nose, throat or eyes, including NO 8. Cancer/ Leukaemia /Lymphoma/ tumour / NO
defective sight or hearing and discharge from the ears cyst/ Any other growth / lumps/ blood disorder
/enlarged glands
9.Paralysis/epilepsy/ insanity/ tremors, numbness, NO 10. Chronic infections- Skin Disease/ skin NO
double vision, dizzy or fainting spells/ head Injury / eruption/ Leprosy / ,Filariasis, Gonorrhoea,
insomnia/ nervous breakdown / Mental Disorder syphilis or any other venereal disease or
(Depression/ Anxiety, etc.). / any other disease of the AIDS&HIV related condition
brain or the nervous system

11. Hernia/Hydrocele, Varicocele, fistula NO 12. Any other disease? NO

f If answer to any of the questions mentioned in ‘e’ above is yes, please give details as below ( If hospitalized, enclose the
discharge summary and all investigation papers along with the proposal form.)
Nature of disease / Date of Fully recovered Still on treatment Name and address of
illness Diagnosis (Y/N) (Y/N), If Yes give Doctor/ Hospital
(DD/MM/YYYY) details of treatment
NIL N. N,A N.A N.A
A

II Personal Habits
Do you smoke/consume or have you ever smoked/consumed the Y/N, If yes, quantity If stopped, since
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 following consumed and duration how many months
a Alcoholic drinks NO N.A
b Narcotics NO N.A
cAny other drugs, If yes, which one NO N.A
dTobacco***in any form in past 60 months.(in sticks /packets/sachets or NO N.A
gms /day)
***Tobacco product includes but not limited to cigars, cigarettes, beedis, chewable tobacco like Gutkha, flavoured paan
masala, etc. NO
III Family History(Please mention specifically if suffering from or died of heart disease, stroke, high blood pressure, diabetes
mellitus, cancer, kidney disease or any hereditary disorders, Insanity, or any contagious diseases such as
tuberculosis ,hepatitis, AIDS / HIV etc) NO
Living Dead
Age (in Yrs) State of health Age at death (in Yrs) Year and cause of death
Father 52 GOOD N,A N.A
Mother 59 GOOD N.A N.A
Brothers No. 21 GOOD N.A N.A
1
Sisters No. SINGEL N.A N.A N.A

Spouse SINGEL N.A N.A N.A

Children No. SINGEL N.A N.A N.A

IV For Female Proponents only

a Are you pregnant now? NO
b Date of last delivery (DD/MM/YYYY) N.A
c Have you had any abortion or miscarriage or Caesarean section? If so, give details NO
d Have you ever consulted a gynaecologist or undergone any investigation, treatment for any NO
Gynaec ailment? (If yes, give details)
e Husband’s details BACHLOUR
Husband’s full Name N.A
His Occupation N,A
His Annual Income N,A
f Details of Husband’s Insurance N.A
Policy number Name of branch/ Division/ Name of the Sum Plan & Term Present status of the
insurer ( if other than LIC) from where policy Assured policy
has been taken
N,A N.A N.A N.A N.A
DO DO DO DO DO
DO DO DO DO DO
DO DO DO DO DO
DO DO DO DO DO

Section IV: Declaration

DECLARATION BY THE LIFE TO BE ASSURED

I _NAVYA__KHANDELWAL________________________________________ 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.

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Not-withstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor,
hospital ,diagnostic center and/or employer, reinsurer/ credit bureau from divulging any knowledge or information about me
concerning my health or employment , occupation, insurance , financial etc. on the grounds ofprivacy, 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 the Corporation to divulge the same to any Authorised Organisation /
Institution / Agency / and Governmental / Regulatory Authority for the sole purpose of underwriting / investigation / risk
mitigation / fraud control and/or claim settlement. 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 my occupation or any adverse circumstances connected with my
financial position or the general health of myself or that of any members of my family occurs or (ii) if a proposal for assurance or
an application for revival of a policy on my life made to any office of the Corporation is withdrawn or dropped, deferred or
accepted at an increased premium 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. Any omission on my part to do so shall render this contract to be
dealt with as per provisions of Section 45 of the Insurance Act, 1938 as amended from time to time.

I am aware that if the information on my Tax Residency is found to be false or untrue or misleading or misrepresenting, I may be
held liable for it. I also undertake to inform the Corporation of any change in my Tax Residency status.

I undertake to inform the Corporation immediately of any changes in KYC documents such as residence. I also give my
consent to obtain and share my data from / with Central KYC Registry respectively and to receive phone calls ,
SMS/ E mail from Central KYC registry in this regard.
I understand that the Corporation reserves the right to accept /Postpone/ drop/ decline or offer alternate terms on this proposal for
life insurance.

I hereby give my consent to receive phone calls, SMS/whatsapp messages, E mail on the above mentioned registered
number(s)/ E mail address from / on behalf of the Corporation with respect to my life insurance policy/regarding servicing of
insurance policies/ notifying about the status of Claim
I also understand that the premium and benefits under the policy are subject to taxes / duties/ charges in accordance with the laws
as applicable from time to time.

Dated at ___KOLKATA_________________ on the 5TH _______ day of NOVEMBER__________ 2024______

_______________________________ _____________________________________________
Signature or Thumb impression of Witness Signature or Thumb impression of the Life to be assured

Name, Occupation & Address:

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 Life to be assured is person with disability (PWD) where he/she is not able to fill the proposal form
himself/ herself.)

“I hereby declare that I have fully explained the above questions to the Life to be assured and I have truthfully recorded the
answers given by the Life to be assured and Life to be assured has affixed the thumb impression/ signature as below after
fully understanding the contents thereof.”

Name and Address of the Declarant:________________ Signature:____________________

“I certify that the contents of the form have been fully explained to me by (Name, Designation, occupation) Mr. /
Ms.:_______________________________________________

Signature or Thumb impression of the Life to be assured: _____________________

2. In case the Life to be assured is illiterate, his/her thumb impression 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 the above questions and contents of the proposal form to theLife to be assured in
______________language, and that the Life to be assured has affixed the thumb impression above after fully understanding
the contents thereof.”

Signature: ____________________
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 Name and Address of the Declarant: ________________

SECTION 45 OF THE INSURANCE ACT,1938

(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.
____________________________________________________________________________________________ In accordance
with the applicable provision of Section 41 of the Insurance Act, 1938:
“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 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 prospectus or
tables of the insurer”
______________________________________________________________________________________________
Various Sections of the Insurance Act, 1938 applicable to LIC to apply as amended from time to time.

Please visit our site www.licindia.in and register yourself with LIC Portal after completion of this proposal to avail the benefit
of e services.

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Proposal No. to be furnished by the Proposer/ Life to be assured

Addendum to Proposal Form for Settlement Option (for Maturity Benefit) Do you wish
to avail Settlement Option (for Maturity Benefit) under the proposal NO

If yes, please Tick/Strikeout (if not applicable) the following:

1. Period for settlement option (in years): 5 / 10 / 15 (As applicable under the plan) N.A
2. Whether Settlement Option (for Maturity Benefit) is required for: Full / Part of the benefit proceeds If in part, specify
the amount/ percentage of the benefit proceeds:
Absolute amount (in Rs): -----------NO------
Percentage of benefit proceeds: ---------NO--------
3. Mode of Instalment payment: Yearly / Half-Yearly / Quarterly / Monthly N.A

If the Net Claim Amount is less than the required amount to provide the minimum instalment amount (as mentioned below) as
per the option exercised by the Proposer/Life to be Assured, the claim proceed shall be paid in lump sum only.
Mode of Instalment payment Minimum Instalment amount (Rs)
Monthly N.A Rs. 5,000/- N.A
Quarterly N.A Rs. 15,000/- N.A
Half-Yearly N.A Rs. 25,000/- N.A
Yearly N.A Rs. 50,000/- N.A
Place &Date (DD/MM/YYYY)

Name &Signature / Thumb impression of the Life to be Assured

Addendum to Proposal Form for Option to take Death Benefit in Instalments

Do you wish to make provision for your nominee/s to avail the Option of receiving if the unfortunate circumstances arises, Death
Benefit in Instalments under the proposal ? NO

If yes, please Tick/Strikeout (if not applicable) the following: N.A

1. Period forOption to take Death Benefit in Instalments (in years): 5 / 10 / 15 (As applicable under the plan)
2. Whether Option to take Death Benefit in Instalments is required for: Full / Part of the benefit proceeds If in part,
specify the amount/ percentage of the benefit proceeds:
Absolute amount (in Rs): ---------------N.A--
Percentage of benefit proceeds: -----------------
3. Mode of Instalment payment: Yearly / Half-Yearly / Quarterly / Monthly N.A

If the Net Claim Amount is less than the required amount to provide the minimum instalment amount (as mentioned below) as
per the option exercised by the Proposer/Life to be Assured, the claim proceed shall be paid in lump sum only.
Mode of Instalment payment Minimum Instalment amount (Rs)
Monthly N.A Rs. 5,000/- N.A
Quarterly N.A Rs. 15,000/- N.A
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 Half-Yearly N.A Rs. 25,000/- N.A
Yearly N.A Rs. 50,000/- N.A
KOLKATA ON 5THNOVEMBER 2024

Name &Signature / Thumb impression of the Life to be Assured

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