1.

PLI Proposal Form 1-8

2. RPLI Proposal Form 9-13
3. Proposal Form For APS 14-18
4. Proposal Form For Children Of ARMY Person 19-22
5. Proposal Form for Children Policy 23-26
6. Form of Exercising Option for Conversion of CWA Policy into EA Policy 27
7. Claim Form For MATURITY/SURVIVAL Benefit Of PLI/RPLI Policy 28-30
8. LETTER Of INDEMNITY(If original policy bond lost (FOR MATURITY/SURVIVAL/SURRENDER CLAIM) 30-31
9. Claim Application Form for PLI/RPLI (Death Cases) 33-36
10. LETTER OF INDEMNITY for death claim (in absence of Original Policy document) 37-38
11. Indemnity bond in case of unnatural death of policy holder 39-40
12. Application For Loan On Security Of PLI/RPLI Policy 41-43
13. Application for Assignment or reassignment 44
14. APPLICATION FOR SURRENDER OF PLI/RPLI 45
15. Request for Registration/ Change of Nomination in respect of PLI/ RPLI Policy 46-47
16. Duplicate Premium Book Form 48
17. ECS Form For Standing Instruction from POSB 49
18. Revival Form for PLI/RPLI 50

Source-www.indiapost.gov.in
 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
1
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
2
 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
3
 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
4
 (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
5
 (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
6
*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
7
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
8
 Affix here your
recent passport
size photograph

DEPARTMENT OF POSTS
PROPOSAL FORM FOR RURAL POSTAL LIFE INSURANCE (RPLI)
(All entries should be filled in CAPITAL letters)
Agent/Advisor Code: _____________________

Agent/ Sales person Name: _______________________ Group Leader Name & Code: __________________________
Proposal Date
d d / m m / y y y y
Date of Declaration
d d / m m / y y y y
Product/ Policy Type: □
WLA □
CWLA EA AEA □ □ □GY
Do you already have any PLI/RPLI policy: Yes / No
Customer ID _______________________ (for existing customers)
1. Proposer’s Details:

i. Name of Proponent Mr. Mrs. Ms.)

First Name Middle Name Last Name

ii. Aadhaar No._________________________________ (optional) iv. PAN _________________________ (optional)

iii. Father’s Name OR Mother’s Name
First Name Middle Name Last Name

iv. Gender v. Date of Birth (dd/mm/yyyy) vi. Marital Status Married Unmarried Others
M F Others d d / m m / y y y y

vii. Age Proof: [Tick (√) whichever is applicable]

(Standard Age Proof)
Birth Certificate Matriculation Certificate Driving License Passport PAN Others
Non standard Age Proof: ______________________________ (please specify)

vi. FOR FEMALE PROPONENT ONLY

Number of Children Are you Pregnant now? If pregnant, expected month of delivery

Yes No

2. Contact Details
i Correspondence Address
Tick here if permanent address is same (√)
Correspondence Address: Permanent Address:

Village/Locality: _________________________ Village/Locality: _________________________

Post Office: _____________________ Taluka/District: __________ Post Office: _____________________ Taluka/District: __________
State: Pincode: State: Pincode:
Mobile No: ________________________ Mobile No: ________________________
Email address: (if any) Email address: (if any)

3. Proposer’s Occupation and Income Details:

Occupation: ___________________________________________________

PAN No. (if any)

Monthly Income

4. Nomination Details (refer Section 39 of Insurance act 1938)

a. Details of Nomination (Not more than 3 nominees)
Name & address of the Nominee(s) Gender Date of Birth Aadhaar No. Relationship Share of Mobile & email ID
(M/F/Other) (DD/MM/YYYY) (optional) Nominee(s) %

1.

2.

3.

9
b. Appointee Details (If nominee is minor)
First Name Middle Name Last Name

Relationship. Gender M F

Date of Birth d d / m m / y y y y

Mobile No. __________________________________

C. Particulars of beneficiary(ies), if policy is taken under Married Women Property Act 1874, (nomination in such cases are not
allowed).
________________________________________________________________________________________

5. Additional Policy Details, if any:

i. Particulars of other PLI/RPLI policies already held, if any:

Sl. No. Policy No. Type PLI/RPLI/Others Sum Assured (in ₹) Maturity Date
1
.2
.3
.4
. Total: (in ₹)
*Present aggregated sum assured limit for RPLI Policies is Rs.10,00,000/- (including the existing proposal) and aggregated sum assured limit
for PLI/RPLI Policies both is Rs.50,00,000/-.
6. Coverage Details
i. Age at Maturity/ Premium ceasing age ii. Policy Term iii. Sum Assured
Years Years ₹

7. Premium Details
i. Premium ii. Initial Premium Payment Mode iii. Subsequent Premium Payment Mode Cash / Online

₹ / -
(Cash/Cheque/Credit Card/Debit Card)

iv. Premium Payment Frequency Monthly Quarterly Half Yearly Yearly

8. Proponent’s Health Information

a. Are you in sound health at present? Yes No

b. Have you ever suffered/suffering from any of the following? (Say Yes or No)
YES NO
(i) High blood pressure, angina, heart attack, stroke or any other disorder of heart or circulation? :

(ii) Diabetes, Kidney or liver problem? :

(iii) Colitis or any other stomach, bowel or bladder growth? :
(iv) Asthma, bronchitis, pneumonia, TB or any other respiratory or lung disorder? :
(v) Ulcer, chronic diarrhea, hepatitis or jaundice? :
(vi) Congenital disorder, anaemia, bleeding or blood disorder? :
(vii) Disorder of Skin or Lymph glands? :
(viii) Mental or nervous illness (including depression) lasting for more than 3 months and/or requiring more than 10 :
consecutive days off work?
(ix) Reproductive organ or prostrate disorder? :
(x) Arthritis, gout or joint pain, muscle, bone fracture or disorder? :
(xi) AIDS OR AIDS related complication or test indicating presence of HIV? :
(xii) Any form of cancer, tumour or growth?
(xiii) Any other illness, surgery or inquiry? :
(xiv) Any physical deformity or handicap? :
(xv) Epilepsy :
(xvi) Paralysis :

c. Have you ever been hospitalized during the last 3 years? If so, furnish the following information.

Sl. No. Name of Hospital Period of Hospitalization Reason for hospitalization

1.

2.

3.

d. Do you have any physical deformity or congenital by birth defects? : Yes No

If Yes, please provide details below:

______________________________________________________________________________________________________________
10
9. Declaration of Proponent

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 Department of Posts 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 Department.

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 on the grounds of secrecy I, my heirs nominee, executors, administrators and assignees
or any other persons 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 Department.
And I further agree that if after the date of the submission of the proposal but before the acceptance of the proposal, (i) any change in my occupation any
adverse circumstance connected with my financial position or the general health of myself or that of any member 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 Department has been withdrawn or dropped, deferred or declined or accepted
at an increase premium or subject to a lien or a term other than as proposed, I shall forthwith intimate the same to the Department in writing to reconsider the
terms of acceptance of assurance. Any omission on my part to do so shall render this assurance invalid and all moneys which shall have been paid in respect
thereof forfeited to the Department.
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.
g)
I __________________________________Son/ Wife/ Daughter of ______________________________ aged ____ years do hereby declare that:

i. I ___________________________________ am not suffering from Hypertension & Diabetes and not taking any treatment for Hypertension &
Diabetes.
OR
I have been suffering from Diabetes/Hypertension from 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.

I___________________________________ hereby agree to pay the fee of ₹ __________ (per individual) for the medical examination if my proposal is
not accepted.
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.

Proponent’s Signature /
Thumb Impression
(in case proposer is illiterate)
Dated: d d / m m / y y y y

10. Declaration in case the proposer is illiterate, and form is filled by person other than proposer

I______________________ hereby declare that I have explained the content of this form to the proposer in
_______________________________ (Language) which he/she easily understands and that the proposer has affixed the thumb impression
above after fully understanding the contents there of. I have carefully filled up the proposal form.

Signature:

Declarant’s Name:
Address:

Date: d d / m m / y y y y
11. Declaration by Agent/Sales Person

I ________________ Agent Code No./ID ____________________________working as in

BO/SO under Division declare that the information (personal,
financial & medical) 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 have been verified and found correct to best of my knowledge. I am fully aware
about financial/physical/mental situation concerning proposer which makes him suitable/unsuitable for the consideration of his Insurance
proposal. The proposal is recommended/not recommended for acceptance. I further undertake that I have carried out required verification
and completed the confidential report & enclosed with this proposal form.
Date: d d / m m / y y y y Signature with Stamp:

Mobile Number: -…………………………………………...

Email Id: -…………………………………………………….

11
11. Medical Examiner’s Certificate
Certified that I have carefully examined Shri/Smt. ___________________________________________________ the proponent, whose
signature/thumb impression is 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 8 & 9, I find the proponent
to be medically fit. He/ She does not suffer from any terminal or other serious health hazard which would be risk to his/her life. I recommend
acceptance of his/her their proposal of Postal Life Insurance policy.
OR
The proponent is medically unfit. I do not recommend acceptance of his/her proposal for Postal Life Insurance policy.
Signature of Medical Examiner:
Signature of Proponent:

Name:
Seal:
Date: d d / m m / y y y y
ID/Code:

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 under weight 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.

FOR OFFICIAL USE ONLY

Proposal No. Date of Receipt / /
No. of LI-7(a) Amount Deposited
Policy No.
PLI Proposal Receipt No.
Premium: _________________

GST: ____________________

Paste Receipt Here

12
Notes/Instructions for filling up the Proposal Form (Not to be scanned & uploaded)

1. Please provide valid proof of your age. In case you are not having any valid proof of date of birth
you may produce any of the following documents (non standard age proof)* :

a. Self-declaration attested by Panchayat member/gram Pradhan.

b. Medical officer’s appropriate age certificate.

c. Voter ID bearing age.

d. Aadhar Card

(*policy(ies) taken on non standard age proof will be charged 5% additional premium)
2. Please mention your mobile number, email ID at appropriate place. Mentioning mobile number
and email address will help us in sending SMS and e-mail alerts to you for various services of .
3. Nomination in Policy will help in timely and hassle-free settlement of claim, if a policy becomes
a claim before date of maturity. Therefore, it is advisable to give nominee (s) details in each case.
4. In case policy is taken under Married Women Property Act 1874, nomination in such case is not
required. In such case name of the beneficiary (i.e. wife) should be mentioned at serl 4 © of
proposal form
5. Mentioning Aadhar/ PAN is optional. However, it would facilitate us to provide better after sales
services.
6. In case of change of address/nomination, proponent is advised to notify the same to nearest CPC
concerned.
7. In case, nominee is minor, particulars of person as appointee should be given at appropriate place.
8. Please mention your Bank Account No. or Post Office Account, if any.
9. Willful concealment of any material information will render the contract voidable at any time.
10. Change of communication address, mobile number or email address may be brought to
information of Department to avail better after sales service.
11. 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 Deptt. and
this declaration should be made by him.

13
 Affix here Affix here
Spouse’s Proponent’s
recent recent
DEPARTMENT OF POSTS passport size passport size
PROPOSAL FORM FOR POSTAL LIFE INSURANCE (APS) 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 `
Agent Code
Post Office at which deposited

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/ Husband’s Name (In case of Yugal Suraksha give father’s name)

iii. Gender iv. Marital Status (Married/ Unmarried) v. Date of Birth (DD/MM/YYYY)
M F / /
vi. 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.
vii. Nationality

viii. 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. Permanent Address

Village Taluka
City District
State Country PIN
ii. Communication Address
UNIT PIN CODE

Page 1 of 5
14
4. Proposer’s Contact Details
i. Phone No. with STD Code ii. Mobile No.

5. Proposer’s Employment Details

i. Service Number ii. Rank

iii Name
iv Occupation:
Army Navy Air Force Para Military Forces Defence Civilian
v. Date of Entry in Service
/ /
vi. PAN No. vii. Monthly Income viii. DDO Code
`
ix. Name of CDA/CDA A/C No(for Officers Only) / PAO (OR) (for PBOR only) x. PAO Code

xi. Office Address: UNIT PIN CODE

xii. Office Phone No. with STD Code

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

Illiterate Other (furnish detail)

6. 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
Share %age: % Gender: M F
Date of Birth: / / Age: Years
Communication Address

Village Taluka
City District
State Country PIN
Phone No.

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
Share %age: % Gender: M F
Date of Birth: / / Age: Years
Communication Address

Village Taluka
City District
State Country PIN
Phone No.

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
Share %age: % Gender: M F
Date of Birth: / / Age: Years

Page 2 of 5
15
 Communication Address

Village Taluka
City District
State Country PIN
Phone No.

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.

7. 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 `)

8. Coverage Details
i. Premium Ceasing Age/
Age at Maturity ii. Policy Term iii. Sum Assured
Years Years ` / -
9. Premium Details
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

10. Proponent’s Health Information

a. Are you and your child in sound health at present? Yes No
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

Page 3 of 5
16
(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/ Diabetes 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.
4.
5.
6.

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 ____________________________________________________________________________________________
f. Particulars of the family doctor, if any:__________________________________________________________________________

11. 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.
g) MY MEDICAL CATEGORY IS SHAPE-1 (Applicable for Defence and Para Military pers only)
h) In the event of my proposal dated _____________________________________ for Postal Life Insurance Policy for the sum of
Rs _________________________________________ being accepted, I hereby authorize Addl DG APS, IHQ of MoD (Army)
to direct _______________________________________ (Name of PAO), being the office maintaining my pay accounts, to
deduct from my pay a sum equal to the amount of the first premium and subsequent premia payable by me with effect from the
month of acceptance of PLI proposal in respect of the said insurance, to receive the said sum from him and apply it towards
payments of the said premium.

(B) I/ We hereby agree to pay the fee of `_______________________(per individual) for the medical examination if our proposal is
not accepted.

________________________________
(Signature of the proposer with service No)
Spouse’s Signature:_______________________
No ___________________________ Rank___________________
Name ________________________________________________
Present unit/office address______________________________
with PIN Code _____________________________

Dated: The ________________Day of ____________________ 20_____

Page 4 of 5
17
12. Certificate of Immediate Superior

(a) Certified that No ____________________Rank ____________Name __________________________________________

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.
(b) It is also certified that the medical category of the above proposer is SHAPE-1 as per his last Medical Examination carried
out on __________________________ (Not applicable for personnel of GREF, Def Civilians/Non Medical Cases).
(c) The form is countersigned in respect of declaration at Serial 11 A(h) above.

Date : __________________ Signature: ________________________

Place: __________________ Name : _______________________

Designation/Seal: __________________
13. To be filled in by DO/ FO (PLI)/ Agent

I No________________________ Rank _________________Name ________________________________________________

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.

DO/FO/Agent’s Signature: ___________________

No ___________________ Rank ______________
Date: _________________ Name ____________________________________

14. Medical Examiner’s Certificate:

Certified that I have carefully examined Shri/ Smt. No ___________________ Rank ____________Name ______________________
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) When there are two or more cases of diabetes in the family, report of Glucose” Tolerance Test and Urine would be required and if
the proponent is overweight in addition to the family history of diabetes or there is a suspicion of sugar in the urine or personal history
of glycosuria, a blood sugar report would be necessary.
b) If the proponent is overweight or has doubtful family history an electrocardiogram and a report on the scanning of the chest would
be required.
c) If the proponent is underweight and has family history of TB, an X-Ray of the chest would be required.
d) Expense of the above mentioned tests will have to be borne by the proponent.

15. Unit Code with Details of Proposal Checked by:

Field Officer DA Asst PO OC (With Rubber Stamp)
Unit Code
Sig

Page 5 of 5
18
 Affix here
Child’s recent
DEPARTMENT OF POSTS passport size
PROPOSAL FORM FOR CHILDREN POLICY (APS) 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 `
Agent Code
Post Office at which deposited

ACG-67 Receipt No. and Date

Policy No.

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

/ / / /

Product/ Policy Type PLI

1. Child’s Details

i. Name of Child
First Name Middle Name Last Name

ii. Father’s Name

iii.Mother’s Name

iv. Gender v. Date of Birth (DD/MM/YYYY) vi. Parent’s Policy Number

M F / /

vi. Age Proof: [Tick (√) whichever is applicable] (Standard Age Proof)

Birth Certificate Matriculation Certificate Driving License Passport PAN

vii. Nationality

2. Address Details

i. Communication Address: UNIT PIN CODE

ii. Permanent Address

Village Taluka
City District
State Country PIN

3. Contact Details

i. Phone No. with STD Code ii. Mobile No.

Page 1 of 4
19
4. Parent’s Employment/ Occupation Details

i. Service Number ii. Rank

iii Name
iv Occupation:
Army Navy Air Force Para Military Forces Defence Civilian
v. Date of Entry in Service
/ /

vi. PAN No. vii. Monthly Income viii. DDO Code

`

ix. Name of CDA/CDA A/C No(for Officers Only) / PAO (OR) (for PBOR only) x. PAO Code

xi. Office Address: UNIT PIN CODE

xii. Office Phone No. with STD Code

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

Illiterate Other (furnish detail)

5. Additional Policy Details Held by Parents

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 `)

6. Coverage Details

i. Age at Maturity ii. Policy Term iii. Sum Assured

Years Years `

7. Premium Details

i. Premium ii. Initial Premium Payment Mode iii. Subsequent Premium Payment Mode
` / -
(Cash/ Cheque/ Credit Card/ Debit Card/ Salary)

iv. Premium Payment Frequency

Monthly

Page 2 of 4
20
8. Health Information

a. Are you and your child in sound health at present? Yes No

b. Have your child ever suffered/ suffering from any of the following? (Say Yes or No)

Child
(i) Tuberculosis : Yes No
(ii) Cancer : Yes No
(iii) Paralysis : Yes No
(iv) Insanity : Yes No
(v) Any disease of heart and lungs : Yes No
(vi) Kidney disease : Yes No
(vii) Any disease of brain : Yes No
(viii) HIV Positive : Yes No
(ix) Hepatitis-B : Yes No
(x) Epilepsy : Yes No
(xi) Nervous disorder : Yes No
(xii) Liver : Yes No
(xiii) Leprosy : Yes No
(xiv) Any physical deformity or handicap : Yes No
(xv) Any other serious disease : 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/ Diabetes etc?

Yes No

If yes, give details: ___________________________________________________________________________________________

d. Have child hospitalized during the last 3 years? If so, furnish the following information.

Ailment Name of Hospital Period of Hospitalization

From To
1.
2.
3.

e. Does the child 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 ____________________________________________________________________________________________

f. Particulars of the family doctor, if any:__________________________________________________________________________

9. Declaration of Parent

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

(B) I hereby agree to pay the fee of `_______________________(per individual) for the medical examination if our proposal is not
accepted.

Parent’s Signature:_________________________________
(Signature with service No)
No _______________________ Rank__________________
Name ___________________________________________
Present unit/office address__________________________
with PIN Code __________________________
Dated: The ________________Day of ____________________ 20____

Page 3 of 4
21
10. Certificate of Immediate Superior

(a) Certified that No ____________________Rank ____________Name __________________________________________

is a permanent/ temporary employee in _____________________________________________________________ and information
furnished against column No. 1 to 4 of this proposal form is correct as per his/ her service records.
Date : __________________ Signature: ________________________
Place: __________________ Name : _______________________
Designation/Seal: __________________

11. To be filled in by DO/ FO (PLI)/ Agent

I No________________________ Rank _________________Name ________________________________________________

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.
DO/FO/Agent’s Signature: ___________________
No ___________________ Rank ______________
Date: _________________ Name ____________________________________

12. Medical Examiner’s Certificate:

Certified that I have carefully examined Master/ Shri/ Ms. __________________________________________________ the
proponent whose signature is 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 11, I find the
proponent to be medically fit. He/ She does not suffer from any terminal or other serious health hazard which would be risk to his/ her
life. I recommend acceptance of his/ her proposal of Postal Life Insurance policy.
OR
The proponent is medically unfit. I do not recommend acceptance of his/ her proposal for Postal Life Insurance policy.

Signature of Child:_____________________ Signature of Medical Examiner: ______________

Name: ___________________________________
Seal : ___________________________________
Date : ___________________________________
ID/ Code : ________________________________

NOTE FOR MEDICAL OFFICER

a) When there are two or more cases of diabetes in the family, report of Glucose” Tolerance Test and Urine would be required and if
the proponent is overweight in addition to the family history of diabetes or there is a suspicion of sugar in the urine or personal history
of glycosuria, a blood sugar report would be necessary.
b) If the proponent is overweight or has doubtful family history an electrocardiogram and a report on the scanning of the chest would
be required.
c) If the proponent is underweight and has family history of TB, an X-Ray of the chest would be required.
d) Expense of the above mentioned tests will have to be borne by the proponent.

13. Declaration for Recovery of Premia

In the event of my proposal for my son/daughter dated________________________________ for Postal Life Insurance Policy for the
sum of Rs ________________________________________________________ being accepted. I hereby authorise Addl DG APS,
IHQ of MoD (Army) to direct ___ _________________________________________________ (Name of PAO), being the office
maintaining my pay accounts, to deduct from my pay a sum equal to the amount of the first premium and subsequent premia payable
by me with effect from the month of acceptance of PLI proposal in respect of the said insurance, to receive the said sum from him and
apply it towards payments of the said premia.
Station: _________________ Signature: ________________________________
No ___________________ Rank ______________
Dated: _________________ Name ____________________________________

COUNTERSIGNED

_______________________________________
Dated: _________________ (Signature of Officer with name and designation stamp)
Seal____________________________________

14. Unit Code with Details of Proposal Checked by:

Field Officer DA Asst PO OC (With Rubber Stamp)
Unit Code
Sig

Page 4 of 4
22
 Affix here
Child’s recent
passport size
DEPARTMENT OF POSTS photograph
PROPOSAL FORM FOR CHILDREN POLICY
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 `
Agent Code
Post Office at which deposited

ACG-67 Receipt No. and Date

Policy No.

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

/ / / /

Product/ Policy Type PLI RPLI

1. Child’s Details

i. Name of Child
First Name Middle Name Last Name

ii. Father’s Name

iii.Mother’s Name

iv. Gender v. Date of Birth (DD/MM/YYYY) vi. Parent’s Policy Number

M F / /
vi. Age Proof: [Tick (√) whichever is applicable] (Standard Age Proof)
Birth Certificate Matriculation Certificate Driving License Passport PAN
(Non-Standard Age Proof) (In case of RPLI only)
Horoscope Elder’s Declaration Aadhaar Card Medical Examiners Approximate age certificate

Dec by insurant counter signed by Panchayat Member Only month year of Birth is known

vii. Nationality

2. 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

3. Contact Details

i. Phone No. with STD Code ii. Mobile No.

iii. E-mail ID (If any)

Page 1 of 4
23
4. Parent’s Employment/ Occupation Details

i. Occupation:
Central Govt State Govt PSU Railway Bank Telecom Contractual Joint Venture
Defence Para Military Force Cooperative Society Deemed University/ Educational Institution
Agriculture Teacher Carpenter Labour Tailor Blacksmith Doctor Cobbler

Fisherman Postmaster Goldsmith Canner Priest Mason Potter Electrician

Housewife Weaver Dhobi Barber Milk vendor Business Vegetable vendor Driver
Mechanic Mid wife Govt employee Private employee Un-employed Student Taper
Toddy worker 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)

5. Additional Policy Details Held by Parents

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 `)

6. Coverage Details

i. Age at Maturity ii. Policy Term iii. Sum Assured

Years Years `

7. Premium Details

i. Premium ii. Initial Premium Payment Mode iii. Subsequent Premium Payment Mode
` / -
(Cash/ Cheque/ Credit Card/ Debit Card/ Salary)
iv. Premium Payment Frequency
Monthly

Page 2 of 4
24
8. Health Information
a. Are you and your child in sound health at present? Yes No

b. Has your child ever suffered/ suffering from any of the following? (Say Yes or No)
Child
(i) Tuberculosis : Yes No
(ii) Cancer : Yes No
(iii) Paralysis : Yes No
(iv) Insanity : Yes No
(v) Any disease of heart and lungs : Yes No
(vi) Kidney disease : Yes No
(vii) Any disease of brain : Yes No
(viii) HIV Positive : Yes No
(ix) Hepatitis-B : Yes No
(x) Epilepsy : Yes No
(xi) Nervous disorder : Yes No
(xii) Liver : Yes No
(xiii) Leprosy : Yes No
(xiv) Any physical deformity or handicap : Yes No
(xv) Any other serious disease : Yes No

c. Has any of family members of child (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 child hospitalized during the last 3 years? If so, furnish the following information.

Ailment Name of Hospital Period of Hospitalization

From To
1.
2.
3.

e. Does the child 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:__________________________________________________________________________

9. Declaration of Parent

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

(B) I hereby agree to pay the fee of `_______________________(per individual) for the medical examination if our proposal is not
accepted.

Parent’s Signature:_______________________

Dated: The ________________Day of ____________________ 20____

10. Certificate of Immediate Superior

Certified that ____________________________________________________ is a permanent/ temporary employee in

______________________________________________________________ and information furnished against column No. 1 to 4 of
this proposal form is correct as per his/ her service records.

Date : __________________ Signature: ________________________

Place: __________________ Name : _______________________

Page 3 of 4
25
 Designation/Seal: __________________
11. 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: __________________________

12. Medical Examiner’s Certificate:

Certified that I have carefully examined Master/ Shri/ Ms. __________________________________________________ the
proponent whose signature is 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 11, I find the
proponent to be medically fit. He/ She does not suffer from any terminal or other serious health hazard which would be risk to his/ her
life. I recommend acceptance of his/ her proposal of Postal Life Insurance policy.
OR
The proponent is medically unfit. I do not recommend acceptance of his/ her proposal for Postal Life Insurance policy.

Signature of Child:_____________________ Signature of Medical Examiner: ______________

Name: ___________________________________
Seal : ___________________________________
Date : ___________________________________
ID/ Code : ________________________________

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.

13. Confidential Report (Applicable only in case of Children Policy under RPLI)
This will consist of information not revealed in the proposal form. SDI/ ASP report is not only required for granting a policy but will also
be required when claim arises, to check the correctness of data in proposal form. This will be completed by SDI/ ASP after proposal
form is completed by proposer. Content of the report should not be discussed with the proposer or divulged to him.
(The form should be completed by SDI/ ASP)

1. Are you related to the proposer? : Yes No

2. Are you aware of any financial/physical/mental situation concerning :
proposer which makes him unsuitable for consideration of his Yes No
Insurance proposal?
3. In case of any doubt, please visit the concerned police station and verify :
if the proponent was ever arrested/ convicted in the criminal case. If yes, Yes No
give details.
4. Has he signed proposal/Declaration form? : Yes No
5. Any other matter you would like to bring to the notice of Proposal :
Yes No
accepting authority.
6. Do you recommend the acceptance of the proposal? : Yes No
7. If not recommended, give reasons. : Yes No
8. Please confirm that :-
(1) Confidential report has been written by you after completion of :
Confirmed Not Confirmed
proposal form by proposer.
(2) Confidential report has not been divulged to proposer/ or discussed : Confirmed Not Confirmed
with him.

Signature of SDI/ ASP

Full Name With Stamp

Page 4 of 4
26
 Form of Exercising Option for Conversion of CWA Policy into EA Policy
(after completion of five years but within sixth year)
(Please fill in the columns in CAPITAL letters)

1. Name of Insurant (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

2. Occupation

3. Communication Address

Village Taluka
City District
State Country PIN

4. Particulars of Policy which has to be converted

i. Policy No.

ii. Sum Assured iii. Date of Acceptance iv. Premium Ceasing Age
` / - / / Years

5. Term of Endowment Assurance the insurant opts to convert the CWA policy by exercising the
option
EA (Fill here 50/ 55/ 58 in case of PLI or 50/ 55/ 58/ 60 in case of RPLI policy)

I, _______________________________________________ (Name) the holder of aforesaid

policy agree to pay the premium on enhanced rate towards my policy on conversion to Endowment
Assurance and also abide to accept the terms & conditions prescribed in Post Office Life Insurance
Rules-2011, as amended time-to-time by Director General of Posts.

Date:________________
Signature of Insurant
Name:………………………
Phone no.: …………………
Office:………………………
Residence: …………………
Mobile no.: …………………
Documents attached:

a) Policy document duly

b) Premium Receipt Book
d) Certificate of Pay Disbursing Officer regarding recovery of premia from pay for the last six months.

27
Annex - II

CLAIM FORM FOR MATURITY/SURVIVAL BENEFIT OF PLI/RPLI POLICY

(Please fill in BLOCK letters)

Service Request No. :

(For Official only)
1 Policy Details :

i Policy Type: ii Policy No. :

iii Name of Insurant : iv Sum Assured :

Date of Acceptance :
v vi Premia Frequency (Monthly/Quarterly etc):
(dd/mm/yyyy)
Date of Survival Benefit Due : Date of Maturity :
vii (dd/mm/yyyyy) OR (dd/mm/yyyyy)
(AEA Policy)

viii Loan taken against policy : Yes No

Date of last Installment of Loan Repayment :

If yes, Loan Sanction Amount :
(dd/mm/yyyy)
2.
Outstanding Loan Amount :

Missing Credit Premium Details: …………………………………………………………………………

3.
(in case any premia paid is not included in the Intimation Letter)

4. Communication Address :

Address :

District : State :

PIN Code : Contact Phone Number :

Aadhar Number : e-Mail ID :

5. Name of Spouse (in case of Yugal Suraksha Policy):
6. Office Address of DDO (For Pay Recovery Policy only)

Name & Designation of DDO: Name of Organization:

Office Address: District & State :

PIN Code : Phone no & email id:

7. Account Details (if payment desired through NEFT/Credit)

Bank Account Details Post Office Saving Bank Account Details

Account Number: Account Number:

Account Type: Name of Account Holder

OR
Name of Account Holder: Post Office Name :

Name of Bank: CBS Post Office (Y/N):

Address or Branch Name: Pin code/SOL ID

28
 IFSC code: First page of Pass Book Enclosed (Y/N)

Cancelled Cheque Enclosed (Y/N):

Documents Enclosed: Yes/No/ NA(Not Applicable)

1. Original Policy Bond or Letter of Indemnity

2. Self Attested copy of ID proof of the Insurant

3. Self Attested copy of address proof of the Insurant

4. Documents of Credit /Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid

premium not updated on McCamish Software)

5. Loan Receipt Book (if outstanding loan amount as mentioned in Intimation letter and Loan Receipt book differs)

6. Cancelled Cheque of Insurant Bank Account for Bank Mandate or self attested copy of POSB passbook

7. Self-Attested Copy of ID proof of Messenger (if messenger appointed by Insurant for submission of Maturity claim form)

8. Self-Attested Copy of Address proof of Messenger (if messenger appointed by Insurant for submission of Maturity claim form)

9. Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited hospital

Or
self-attested copy of passport clearly showing visa details and date of departure from India In case messenger is appointed

10. Any other document(s), pls specify ………………………………………………………………………………………………

Date : ______________

Appointment of Messenger
(Required only if Maturity/Survival claim form is being submitted through Messenger)

I hereby declare that I …………………………………………(insurant name), am unable to visit post office, being medically unfit

or outside India, for submission of Maturity/survival benefit claim form. I hereby appoint Shri/Smt./Ms.
…………………………………………. (name of messenger), whose signature is given below, as a messenger for submission of my
maturity/survival benefit claim form along with necessary documents.

Signature of Messenger ………………………………..

Name of Messenger ……………………………………
Signature/Thumbprint of Insurant
In case Insurant is illiterate, there should be two literate witnesses-

Witness Name & Address Signature

Witness 1
Witness 2
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
For Official Use
Certified that I have checked all the documents enclosed and compared with the original documents produced by the
Insurant/messenger and verified the averments made in the Maturity claim form based on these documents and found no
discrepancies.

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:

29
 Acknowledgement Slip
(To be filled by BPM/SPM/Post Master/CPC in-charge and Handed Over to Insurant)

Maturity/Survival Benefit Claim Form for Policy No.___________________________with Service Request No.________________
received on …………………along with following documents:
Documents Enclosed: Yes/No/ NA(Not Applicable)

1. Original Policy Bond or Letter of Indemnity

2. Self Attested copy of ID proof of the Insurant

3. Self Attested copy of address proof of the Insurant

4. Document(s) of Credit or Premium Receipt Book

5. Loan Receipt Book

6. Cancelled Cheque of Insurant Bank Account for Bank Mandate or self attested copy of POSB passbook

7. Self-Attested Copy of ID proof of Messenger

8. Self-Attested Copy of Address proof of Messenger

9. Self-Attested medical certificate of insurant from Govt. Hospital/Govt accredited hospital

Or
self-attested copy of passport clearly showing visa details and date of departure from India

10. Any other document(s), pls specify ………………………………………………………………………………………………

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:

30
 Annex-III
LETTER OF INDEMNITY

(To be executed by the Insurant in absence of Original Policy document)

I…………………………………………………… held myself and my family bound to

the Department of Posts (hereinafter called India Post), in the sum of
……………………………………………… (sum assured of the policy) of lawful money to
be paid on demand or without demand to India Post, its attorneys, successors or
assignees for which I bind myself, my executors, administrators, successors, and
representatives, firmly by this declaration.
Whereas on the …………………………………. day of …………………………….. I,
Sh./Smt./Ms.……………………………………………………… (the policy holder), purchased
from India Post, a PLI/RPLI Policy Numbered………………………………..of the sum
assured Rs.…………………………………… bearing a premium of
Rs.…………………per……………(month/quarter/half year/year) payable up to the
…………………………… (month & year) and I have applied to India Post for the
settlement of my Maturity claim and payment of money in respect of the said
policy AND Whereas the policy has been lost/untraceable and is not forth-
coming AND Whereas I have not produced the said policy issued to
……………………………………………………… (name of the Insurant) by India Post AND
Whereas I declare that the said policy has not been assigned or transferred to
anybody or disposed of in any other way with such consideration as here under
is written.

I hereby undertake to refund all the money with interest to India Post in
case of wrong information furnished above leading to unjust payment to me.

Provided further that the liability of sureties hereunder shall not be

impaired or discharged by reason of time being granted or any forbearance act or
omission of India Post or any person authorised by them (whether with or
without the consent or knowledge of the sureties) nor shall be necessary for
India Post to sue me (Claimant) before suing the sureties for amounts due
hereunder.

Signature/Thumb
Impression of the
Insurant
Name
Complete Address
Mob & email Id

31
Signed sealed and delivered by the above

Witness Name, Address and contact details Signature

Witness 1

Witness 2

Sureties Name, Address and contact details Signature

Surety 1

Surety 2

Signed sealed and delivered by the above

Witness for Name, Address and contact details Signature

Sureties

Witness 1

Witness 2

Note: Self Attested copy of ID proof and Address proof of all Sureties and
Witnesses are to be enclosed with this Letter of Indemnity.

32
Annex - I

Claim Application Form for PLI/RPLI (Death Cases)

(Please fill in BLOCK Capitals)

Service Request No. :

(For Official Only)
1 Policy Details :

i Policy No. : ii Name of Insurant :

Date of Acceptance :
iii Sum Assured : iv
(dd/mm/yyyy)

Date of Survival Benefit Due : Date of Maturity :

v vi
(AEA Policy) (dd/mm/yyyy) (dd/mm/yyyyy)
Loan taken against policy : Yes No
vii
(if yes please attach Loan Repayment Receipt Book& fill column 2)
Date of Loan Repayment :
2. Loan Sanctioned Amount :
(dd/mm/yyyy)

3. Details of Death of Insurant:

Date of Death :
i ii Cause of Death :
(dd/mm/yyyy)

iii Place of Death (Full Address with Pin Code) :

4.(A) Details of Claimant-1:

Age of Claimant *:
i Name of Claimant : ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insurant: iv Proof of Relationship ** :

v
Address:

District : State :

PIN Code : Mobile No :

Share of Claim
e-Mail ID :
amount (%) :

4.(B) Details of Claimant-2 (if Claimant is more than one):

Age of Claimant *:
i Name of Claimant: ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insurant: iv Proof of Relationship ** :

v Address:

District : State :

PIN Code : Mobile No :

33
 Share of Claim
e-Mail ID :
amount (%) :

Details of Claimant-3 (if Claimant is more than

4.(C)
one):

Age of Claimant *:
i Name of Claimant : ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insured : iv Proof of Relationship ** :

v Address:

District : State :

PIN Code : Mobile No :

Share of Claim
e-Mail ID :
amount (%) :

5. (A) To be filled If Claimant is a minor (A) if minor Claimant is more than one:

i Name of Guardian/ Appointee : ii Relationship with minor claimant :

iii Is Father of minor claimant deceased (Y/N): iv Is Mother of minor claimant deceased (Y/N):

5. (B) To be filled If Claimant is a minor (B) if minor Claimant is more than one:

i Name of Guardian/ Appointee : ii Relationship with minor claimant :

iii Is Father of minor claimant deceased (Y/N): iv Is Mother of minor claimant deceased (Y/N):

If you are not father or mother of the minor claimant, have you been appointed guardian of the minor claimant by nomination or

under any enactment in force in India? Please state and produce document in support of your claim
v
(Claimant A) _________________________________________________________________________________________

(Claimant B) _________________________________________________________________________________________

Does the minor claimant resides with you :

vi vii Is the minor maintained by you (Yes/No) :
(Yes/No)

6. Account Details (if payment desired through Bank Mandate)

Post Office Bank Account No. :

Name of Account Holder:

Name of Post Office/Bank: Branch:

IFSC code: Cancelled Cheque Enclosed (Y/N):

(*) Age of Claimant in completed years.

(**) Provide any valid document for proof of relationship between Insurant and Claimant.

34
Documents Enclosed: Yes/No/ NA(Not Applicable)

1. Original Policy Bond or Letter of Indemnity (Format at Annex III)

2. Self Attested copy of Death Certificate (issued by Local Administration/register of local board/village panchayat/Medical
Practitioner or Certificate of Doctor, who last attended the insurer clearly mentioning reason of death)

3. Self Attested copy of Succession Cert./Letter of Administration/Probate of Will, if nomination is not available

4. Self Attested copy of ID proof of the Claimant(s)

5. Self Attested copy of address proof of the Claimant(s)

6. Self Attested copy of FIR (in case of unnatural death of Insurant)

7. Self Attested Post-mortem report (in case of unnatural death of Insurant)

8. Cancelled Cheque of Claimant(s)’s Bank Account(s) for Bank Mandate

9. Documents of Credit or Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid

premium not updated on McCamish Software)

10. Loan Receipt Book (if Loan taken on Policy)

11. Indemnity Bond (in case of Unantural death)

12. Any other document(s), pls specify ………………………………………………………………………………………………

Date: ______________

Signature/Thumbprint of Claimant/Guardian of Claimant

In case Claimant/Guardian of Claimant is illiterate, there should be two literate witnesses-

Witness Name & Address Signature

Witness 1
Witness 2

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

For Official Use

Certified that I have checked all the documents enclosed and compared with the original document produced by the claimant and
verified the averments made in the claim form based on these documents and found no discrepancies.

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:

35
 Acknowledgement Slip
(To be filled by BPM/SPM/Post Master/CPC in-charge and Handed Over to Claimant)

Claim Application for Policy No.____________________received on ___________with Service Request No.__________________and

following documents are received from the Claimant:

Documents Received: Yes/No/ NA (Not Applicable)

1. Original Policy Bond or Letter of Indemnity

2. Self Attested copy of Death Certificate (issued by Local Administration/register of local board/village panchayat/Medical
Practitioner or Certificate from Doctor who last attended the insurer clearly mentioning reason of death)

3. Self Attested copy of Succession Cert./Letter of Administration/Probate of Will if nomination is not available

4. Self Attested copy of ID proof of the Claimant(s)

5. Self Attested copy of address proof of the Claimant(s)

6. Self Attested copy of FIR (in case of unnatural death of Insurant)

7. Self Attested Post-mortem report (in case of unnatural death of Insurant)

8. Cancelled Cheque of Claimant(s)’s Bank Account(s) for Bank Mandate

9. Documents of Credit or Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid

premium not updated on McCamish Software)

10. Loan Receipt Book (if Loan taken on Policy)

11. Indemnity Bond (in case of Unantural death)

12. Any other document(s), pls specify ………………………………………………………………………………………………

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:

36
 Annex-III
LETTER OF INDEMNITY

(To be executed by the Claimant in absence of Original Policy document)

I…………………………………………………… held myself and my family bound to

the Department of Posts (hereinafter called India Post), in the sum of
……………………………………………… (sum assured of the policy) of lawful money to
be paid on demand or without demand to India Post, its attorneys, successors or
assignees for which I bind myself, my executors, administrators, successors, and
representatives, firmly by this declaration.
Whereas on the …………………………………. day of ……………………………..
Sh./Smt./Ms.……………………………………………………… (the policy holder), purchased
from India Post, a PLI/RPLI Policy Numbered………………………………..of the sum
assured Rs.…………………………………… bearing a premium of
Rs.…………………per……………(month/quarter/half year/year) payable up to the
…………………………… (month & year) in his/her name AND Whereas I, as the
nominee/legal heir have applied to India Post for the settlement of my claim and
payment of money in respect of the said policy AND Whereas the policy has been
lost and is not forth-coming AND Whereas I have not produced the said policy
issued to ……………………………………………………… (name of the Insurant) by India
Post AND Whereas I declare that the said policy has not been assigned or
transferred to anybody or disposed of in any other way with such consideration
as here under is written.

I hereby undertake to refund all the money with interest to India Post in
case of wrong information furnished above leading to unjust payment to me.

Provided further that the liability of sureties hereunder shall not be

impaired or discharged by reason of time being granted or any forbearance act or
omission of India Post or any person authorised by them (whether with or
without the consent or knowledge of the sureties) nor shall be necessary for
India Post to sue me (Claimant) before suing the sureties for amounts due
hereunder.

Signature/Thumb
Impression of the
Claimant
Name
Complete Address
Mob & email Id

37
Signed sealed and delivered by the above

Witness Name, Address and contact details Signature

Witness 1

Witness 2

Sureties Name, Address and contact details Signature

Surety 1

Surety 2

Signed sealed and delivered by the above

Witness for Name, Address and contact details Signature

Sureties

Witness 1

Witness 2

Note: Self Attested copy of ID proof and Address proof of all Sureties and
Witnesses are to be enclosed with this Letter of Indemnity.

38
 Annex-VI
INDEMNITY BOND

(To be executed by the Claimant in case of Unnatural death of Insurant)

I…………………………………………………… hereby solemnly affirm and declare

that, I am neither involved in nor responsible for, directly or indirectly, death of
the Insurant for the policy number ………………………… for sum assured Rs.
……………………….. I am neither named as suspect/accused nor proposed to be
named as suspect/accused by the Police in the death case of the Insurant.

I hereby held myself and my family bound to the Department of Posts

(hereinafter called India Post) for the sum of ………………………………………………
(sum assured of the policy) along with bonus amount to be paid on demand or
without demand to India Post, its attorneys, successors or assigns or
representatives for which I bind myself, my executors, administrators,
successors, and representatives, firmly by this declaration.

I hereby undertake to refund all the money (sum assured along with bonus
amount paid) with interest to India Post in case of wrong information furnished
above or in case I am later convicted by the Court of Law in the death case of the
Insurant.

Provided further that the liability of sureties hereunder shall not be

impaired or discharged by reason of time being granted or any forbearance act or
omission of India Post or any person authorised by them (whether with or
without the consent or knowledge of the sureties) nor shall be necessary for
India Post to sue me (Claimant) before suing the sureties for amounts due
hereunder.

Signature/Thumb
Impression of the
Claimant
Name
Complete Address
Mob & email Id

Signed sealed and delivered by the above

Witness Name, Address and contact details Signature

39
Witness 1

Witness 2

Sureties Name, Address and contact details Signature

Surety 1

Surety 2

Signed sealed and delivered by the above

Witness for Name, Address and contact details Signature

Sureties

Witness 1

Witness 2

Note: Self Attested copy of ID proof and Address proof of all Sureties and
Witnesses are to be enclosed with this Indemnity Bond.

40
Annex - II
APPLICATION FOR LOAN ON SECURITY OF PLI/RPLI POLICY
(Please fill in BLOCK letters)

Service Request No. :

(For Official only)
1 Policy Details (particular of policy against which the loan is desired):
Name of Insurant :
i Policy No. : ii Name of Spouse (in case of Yugal Suraksha Policy) :

Date of Acceptance :
iii Sum Assured : iv
(dd/mm/yyyy)

Date of Maturity:
v vi Amount of Loan required :
(dd/mm/yyyy)

vii Purpose for which Loan is required :

2. Details of Previous Loan taken on this Policy (if any)

i Amount of Previous Loan : ii Sanction No.:

iii Sanction Date: iv Date of final repayment of previous Loan:

3. Missing Credit Premium Details (Please enclose supporting documents): …………………………………………………………

4. Communication Address :

Address :

District : State :

PIN Code : Contact Phone Number :

Aadhar Number : e-Mail ID :

5. Office Address of DDO (For Pay Recovery Policy only)

Name & Designation of DDO : Name of Organization :

Office Address : District & State :

PIN Code : Phone No. & e-Mail ID :

6. Account Details (if payment desired through NEFT/RTGS/Other Credit)

Bank Account Details Post Office Saving Bank Account Details

Account Number: Account Number:

Account Type: Name of Account Holder

Name of Account Holder: Post Office Name :

OR
Name of Bank: CBS Post Office (Y/N):

Branch Name: Pin code/SOL ID

IFSC code:
First page of Pass Book Enclosed (Y/N)
Cancelled Cheque Enclosed (Y/N):

41
7. Assignment prescribed under Rule 31 of Estate Duty Rules, 1953, in respect of PLI/RPLI Policies assigned to the
President for the purpose of paying Estate Duty:
“I ………………………………………………….. do hereby assign the benefit of all moneys to become payable under the Postal
Life Insurance Policy/Rural Postal Life Insurance Policy No…………………………. assuring the sum of
`……………………………………..(Rs.) to the President of India for the purpose of paying Estate Duty in accordance with the provision
contained in clause (f) of sub section (1) of Section 33 of the Estate Duty Act, 1953, which after my death my estate may become liable to
pay to the Government of India.
Provided, however, that in the event of my surviving the date on which the said policy if so expressed would mature or the policy is
surrendered by me, the benefit of the policy and the right to receive moneys there under shall revert to me as if this assignment had not
been made. It is further agreed that if the policy matures before my death or is surrendered by me, then on my request the Insurer will
upon the delivery of the policy pay all or so much or the sum due to me as may be specified in such request, to the Government of India
under the head “K-Deposits and Advances- deposits bearing interest-other Deposits –Deposits towards payment of Estate Duty” for being
treated as deposits of moneys for the purpose of paying estate duty as provided in clause (g) of Section 33 (1) of Estate Duty Act, 1953
and a receipt of the Government of India shall be an effectual discharge to the Insurer for the moneys so paid to them.
I undertake not to deal with the policy in any way so long as the above assignment is operative, except nominating any person to
receive the balance of the insurance proceeds, after satisfying the Estate Duty demand.
I, hereby certify that no prior assignment of the within policy or any encumbrance against it exists.

Dated ………………… (Signature/Thumbprint of Insurant)

Place : …………………
Witness : ………………………….. Name & Address of witness:- …………………………………………………….……..
….…………………………………………………………………………………………………………………. (Copy of self attested
ID and address proof of witness is enclosed)
8. Appointment of Messenger (if loan application submitted by messenger)*:
I hereby declare that I, …………………………………………(insurant name) am unable to visit post office , being medically unfit
or outside India, for submission of loan application. I appoint Shri/Smt./Ms. …………………………………………. (Name of
messenger) as a messenger for submission of my loan application and request you, please allow him/her for submission of the loan
application along with necessary documents.
Name of Messenger ……………………………………
Signature of Messenger ………………………………..
Signature or thumbprint of Insurant ……………………………..
Signature/Thumbprint of Insurant
Documents Enclosed: Yes/No/ NA (Not Applicable)
1 Self Attested copy of Policy Bond
Document (s) of Credit (if pay policy)
2 Or In case, any premia payment is made in addition to the details available in
Premium receipt book (if cash policy) loan quote
3 Self Attested copy of ID proof of the Insurant
4 Self Attested copy of address proof of the Insurant

5 Loan Repayment receipt Book (in case any loan re-payment is made in addition to the detail available in loan quote)

6 Cancelled Cheque of Insurant Bank Account for Bank Mandate Or self attested copy of POSB Passbook First Page

7 Self-Attested Copy of ID and address proof of Messenger (if messenger appointed by Insurant for submission of Loan
application form)
Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited Hospital
8 Or for Appointing a
Self-Attested copy of passport clearly showing date of departure from India messenger
9 Any other document(s), pls specify …………………………………………………………………………………………
Date: ______________
Signature/Thumbprint of Insurant
In case Insurant is illiterate, there should be two literate witnesses-
Witness Name & Address Signature
Witness 1
Witness 2
For Official Use
Certified that I have checked all the documents enclosed and compared with the original document produced by the
Insurant/messenger and verified the averments made in the Loan application based on these documents and found no
discrepancies.
Date:- Signature of BPM/SPM/PM/ CPC in-Charge
Name:
Designation:
Office Stamp:
42
 Acknowledgement Slip
(To be filled by BPM/SPM/Post Master/CPC in-charge and Handed Over to Insurant)

Loan Application for Policy No.________________received on ___________with Service Request No.________________and following
documents are received from the Insurant:
Documents Enclosed: Yes/No/ NA (Not Applicable)
1 Self Attested copy of Policy Bond

Document (s) of Credit (if pay policy)

2 Or In case, any premia payment is made in addition to the details available in
Premium receipt book (if cash policy) loan quote

3 Self Attested copy of ID proof of the Insurant

4 Self Attested copy of address proof of the Insurant

5 Loan Repayment receipt Book (in case any loan re-payment is made in addition to the detail available in loan quote)

6 Cancelled Cheque of Insurant Bank Account for Bank Mandate Or self attested copy of POSB Passbook First Page

7 Self-Attested Copy of ID and address proof of Messenger (if messenger appointed by Insurant for submission of Loan
application form)
Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited Hospital
8 Or for Appointing a
Self-Attested copy of passport clearly showing date of departure from India messenger

9 Any other document(s), pls specify …………………………………………………………………………………………

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:

43
 Annex - III
(Assignment/Re-assignment Details (if Loan taken from organization other than India Post):
Application for Assignment or Re-assignment (Tick whichever is applicable)

1 Policy Details (particular of policy against which the loan is taken):

i Policy No. : ii Name of Insurant :

Date of Acceptance :
iii Sum Assured : iv
(dd/mm/yyyy)

Date of Maturity:
v vi Amount of Loan required :
(dd/mm/yyyy)

vii Purpose for which Loan is required Or was taken :

2 Details of Bank/Financial Institution etc. (from which loan is being taken Or was taken):
Name of Bank/Financial Institution etc.: Industry Type : Bank/Financial Institution/Capital Market
i ii
Intermediary/Other

Official Address of Bank/Financial Institution etc:

iii Regulated By: IRDA/RBI/SEBI/Other iv

v Contact No.: vi e-Mail ID :

vi Loan Amount : xv Loan Sanction letter No. (Copy attached):

Loan Sanction Letter No. & date (copy attached in case of assignment of the policy) :
3 Or
Loan Repayment letter No. & date (copy attached in case of Re-assignment of the policy) :

Terms & Conditions (in case of Assignment)

 All future premiums shall be paid by the Assignor (Insurant) of the Insurance policy.
 The assignor (Insurant) shall not exercise or hold any rights pertaining to services of the insurance policy including partial
withdrawal/surrender without specific consent of the assignee (Bank/financial institution etc).
 The Assignor (Insurant) with suitable concurrence from the Assignee (Bank/financial institution etc) shall intimate India Post about
its loan closure for suitable reassignment of the insurance policy to the Assignor (Insurant).
4(A) Declaration (in case of assignment)
This is to put on record that Shri/Smt./Ms ………………………………………….. (Name of insurant) is taking loan of
Rs…..………………………………from …………………………………..…………………. (Bank/Financial Institution etc name)
for ………………………………………….. (purpose) in terms of the Loan agreement dated …………………..
I/We hereby declare that receipt of benefits arising under the policy by the Assignee (Bank/financial institution etc), shall be
valid for sufficient discharge of the said loan. Policy servicing requests, as applied to the Policy prior to this Assignment, would
continue unless specific instructions are provided to the Bank/Financial Institution etc by both the Assignor and the Assignee. I had
by recognized the assignee (Bank/Financial Institution etc) as the only person entitled to the benefit under the policy until the policy
is re-assigned.
I/We do hereby declare that I/we have read and understood the Terms & Conditions mentioned herein above and agree to abide
by the same.
Date:
Place:
Signature of Assignor (Insurant) Signature of Assignee with stamp
4 (B) Declaration (in case of re-assignment)
This is to put on record that Shri/Smt./Ms ………………………………………….. (Name of insurant) to whom
…………………………………………. (Bank/Financial Institution etc name) had been granted a Loan of
Rs.…………………………………… for …………………………………………..(purpose) in terms of the Loan agreement dated
………………… and has/have since repaid the same in full with all dues and that no amount is now due from him/her towards or in
respect of the said loan.
In view of the above ……………………………………….. (Bank/Financial Institution etc name) has no claim right, title or
interest in respect of PLI/RPLI Policy.
I/We do hereby declare that I/we have read and understood the Terms & Conditions mentioned herein above and agree to abide
by the same.
Date:
Place: Signature of Assignor with stamp Signature of Assignee (Insurant)

44
 APPLICATION FOR SURRENDER OF POSTAL/ RURAL LIFE INSURANCE POLICY
(Please fill in the columns in CAPITAL letters)

1. Details of Policy to be surrender

i. Policy No.

ii. Sum Assured iii. Date of Acceptance iv. Date of Maturity

` / - / / / /
2. Name of Insurant (Mr./ Mrs./ Ms.)
First Name Middle Name Last Name

3. Communication Address

Village Taluka
City District
State Country PIN

4. Details of loan taken on policy, if any

i. Sanction Date: / /
ii. Amount of Loan: ` / -
iii. Date of repayment of loan: / /
5. Reasons/ circumstances for surrendering policy _______________________________________________________

6. Name of the Post Office (if it is Sub Office, write the name of Head Office as well) at which the payment is desired.
i. Name of Sub Post Office

ii. Name of Head Post Office

7. For payment of surrender value through cheque, please provide following information about your Post Office/Bank
account:-

i. Account No.

ii. Name of Post Office/ Bank

iii. Branch Name:

8. (i) Designation and Address of Drawing and Disbursing Officer during last six months

Village Taluka
City District
State Country PIN

ii. Name of the Post Office where premia were paid during last six months.

a) b) c)

d) e) f)

Date:________________
Signature of Insurant
Name:
Phone no.:
Office:
Residence:
Mobile no. :

Documents attached:

(a) Policy document.

(b) Loan Repayment Receipt Book relating to previous loan.
(c) Premium Receipt Book.
(d) Certificate of Pay Disbursing Officer regarding recovery of premia from pay for the last six months.

45
Request for Registration/ Change of Nomination in respect of PLI/ RPLI Policy
(refer Section 39 of Insurance act 1938) (Not applicable in case of policy under MWPA 1874)
(Please fill in the columns in CAPITAL letters)

1. Name of Insurant (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

2. Occupation

3. Communication Address

Village Taluka
City District
State Country PIN

4. Particulars of Policy:
i. Policy No. ii. Policy Type

iii. Sum Assured iv. Date of Acceptance v. Premium Ceasing Age

` / - / / Years

5. 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: 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 First Nominee Details- (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

Relationship: 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)

46
iii. Third Nominee Details- (Mr./ Mrs./ Ms.)
First Name Middle Name Last Name

Relationship: 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)

Date:________________
Signature of Insurant
Name:………………………
Phone no.: …………………
Office:………………………
Residence: …………………
Mobile no.: …………………

Signature of Witness 1:
Name:…………………………….
Phone no.:……………………….
Office:……………………………
Residence: ……………………..
Mobile no.:………………………

Signature of Witness 2:
Name:…………………………….
Phone no.:……………………….
Office:……………………………
Residence: ……………………..
Mobile no.:………………………

47
 APPLICATION FOR ISSUE OF DUPLICATE PREMIUM BOOK

(Please fill in the columns in block letters)

1. Policy No. :

2. Sum Assured:

3. Name of Insurant:

4. Address

Pin Code

5. Name of the Post office where premium is paid:

6. Date/Month upto which premium is paid:0/

7. Reason for demanding duplicate passbook:

Date:

Affix receipt of
Rs 20/- here

Signature of Insurant/
Claimant

Name:
Mobile no

Please tender above form in the Post Office where you are paying your premium. The
SPM/BPM of the concerned Post Office will verify, “upto which month you have paid the
premium”

48
49
 APPLICATION FOR REVIVAL OF PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No. :

Date of Acceptance:

2. Name of Insurant:

3. Present address for Correspondence:

Pin Code

4. Date of Maturity:

5. Mode of payment of premia:

6. Period for which premia are due: __________________________________________________

_____________________________________________________________________________

7. Reason for non-payment of premiums if any

____________________________________________________________________________
____________________________________________________________________________

8. Name of the Post Office at which premia are desired to be paid

Name of Sub Post Office:

Name of Head Post Office:

I hereby declare that I continue to be in good health since the date, the first unpaid
premium had become due in respect of above mentioned policy till this date.

Date:
Signature of insurant
Contact no:

MEDICAL CERTIFICATE

I hereby carefully examined

Shri/Smt…………………………………………………………………….......
I am of opinion that he/she is not suffering from any disease likely to shorten life and that
he/she has not had serious disease of a kind likely to recur.

Signature………………………
Place:
Qualification………………………..
Date:
Regn No………………………………..
(Rubber stamp)

50