life insurance corporation of india central office circular_827 with all annexures.pdf · re:...

LIFE INSURANCE CORPORATION OF INDIA CENTRAL OFFICE

Dept: Product Development "Yogakshema" Jeevan Bima Marg Mumbai - 400 021

Ref: CO/PD/57 16th August, 2014

To, All HODs of Central Office All Zonal Offices All Divisional Offices All Branch Offices (through DOs) MDCs, ZTCs, STCs, NIA and Audit & Inspection Depts. of Zonal Offices.

Re: INTRODUCTION OF LIC's JEEVAN RAKSHAK (Plan No.827)

1. INTRODUCTION: It has been decided to introduce LIC's Jeevan Rakshak (Plan No. 827) with effect from 191h August, 2014.

The Unique Identification Number (UIN) for LIC's Jeevan Rakshak Plan is 512N289V01. This number has to be quoted in all relevant documents furnished to the Policyholders and other users (public, distribution channels).

This is a regular premium paying Non-linked, With-Profits, Endowment Assurance plan. This plan shall be available to standard lives only without any medical examination and the total Sum Assured under all the policies issued to an Individual under this plan shall not exceed Rs. 2 lacs. The benefits and other details of the plan are given below.

2. BENEFITS: The benefits payable under an inforce policy are as under:

a) Benefits payable on death: On death of the Life Assured during the policy term "Sum Assured on Death" shall be payable, which is the highest of

• Basic Sum Assured; or • 10 times of annualized premium; or • 1 05% of all the premiums paid as on date of death.

The premium mentioned above excludes taxes, extra premium and rider premiums, if any.

In addition to the above, Loyalty Addition, if any, shall also be payable if death occurs after completion of 5

th policy year.

b) Benefits payable on maturity: On survival to the end of the policy term Basic Sum Assured along with Loyalty Addition, if any, shall be payable.

c) Participation in Profits: Provided the policy is in full force, then depending upon the Corporation's experience the policies under this plan will be eligible for Loyalty Addition. The Loyalty Addition, if any, is payable at such rate and on such terms as may be declared by the Corporation on death after completion of 51h

policy year or on Policyholder surviving to the maturity.

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3. OPTIONAL BENEFIT: This plan provides the following optional rider by payment of additional premium:

LIC's Accident Benefit Rider UIN (512B203V02): LIC's Accident Benefit Rider is available as an optional rider by payment of additional premium during the term of the policy. If there be more than one policy with which this or any other Rider covering Accidental Deaths is attached and if the total Accident Benefit Sum Assured under all such policies exceeds Rs.50 lakhs, the benefits shall apply to the first Rs. 50 lakhs Accident Benefit Sum Assured in order of date of policies issued.

If this benefit is opted for, and if Life Assured is involved in an accident, leading to death and such incident shall occur within 180 days from the date of accident then an additional amount equal to the Accident Benefit Sum Assured is payable. However, the policy shall have to be in force at the time of accident irrespective of whether or not it is in force at the time of death.

The premium rate for this rider is as under; 1. Rs. 0.50 per thousand Accident Benefit Sum Assured irrespective of age. ii. Rs. 1.00 per thousand Accident Benefit Sum Assured. if the Life Assured is engaged in police

duty either in any military, naval or police organization and opts for this cover while engaged in police duty.

Accident Benefit Rider shall not acquire any paid-up value and the rider benefit will cease to apply, if policy is in lapsed condition.

Note: Other than above mentioned LIC's Accident Benefit rider, no other riders including LIC's Accidental Death and Disability Benefit Rider (UIN: 512B209V01) is allowed to be attached with this plan.

4. ELIGIBILITY CONDITIONS AND RESTRICTIONS: For Basic Plan:

1) Minimum Age at entry 2) Maximum Age at entry 3) Minimum Policy Term 4) Maximum Policy Term 5) Maximum Maturity Age for Life Assured 6) Minimum Basic Sum Assured per life 7) Maximum Basic Sum Assured per life

: 8 years (completed) : 55 years (nearest birthday) : 10 years : 20 years : 70 years (nearest birthday)

: Rs. 75,000/-: Rs. 200,000/-

The Basic Sum Assured shall be in multiples of Rs. 5000/-.

"The total Basic Sum Assured under all policies issued to an individual under this plan shall not exceed Rs. 2 lakh". These wordings have to appear in the First Premium Receipt (FPR) and in the policy document for every policy under this plan.

Age at entry for the Policyholder is to be taken as age nearest birthday except for the minimum age at entry i.e. 8 years, where it is in completed years.

For Accident Benefit Rider: 1) Minimum Entry Age : 18 years (completed) 2) Maximum Entry Age : The cover can be opted for at New Business stage or

at any policy anniversary during the policy term. 3) Maximum cover ceasing Age : Same as under the basic plan. 4) Minimum Accident Benefit Sum Assured : Rs. 75,000/-5) Maximum Accident Benefit Sum Assured: An amount equal to the Basic Sum Assured under the

Basic Plan subject to the maximum of Rs.50 lakh overall limit taking all existing policies of the Life Assured under individual as well as group schemes including policies with inbuilt accident benefit

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taken with Life Insurance Corporation of India and the Accident Benefit Sum Assured under the new proposal into consideration.

The Accident Benefit Sum Assured shall be in multiples of Rs. 5,000/-.

5. MODE OF PREMIUM PAYMENT: The modes of premium payment allowable are Yearly, Half Yearly, Quarterly, and Monthly (ECS only or through salary deductions).

6. PREMIUM RATES: The tabular premium rates per thousand Basic Sum Assured are enclosed as Annexure 1. The Class- I extra premium rates per thousand Basic Sum Assured, which may be applicable at revival stage (as only standard lives shall be eligible at NB stage), are enclosed as Annexure 2.

The above premium rates are exclusive of taxes.

7. GRACE PERIOD FOR PAYMENT OF PREMIUM: A grace period of one calendar month but not less than 30 days will be allowed for payment of yearly, half-yearly or quarterly premiums and 15 days for monthly mode of premium payment.

If the death of the Life Assured occurs within the grace period but before the payment of premium then due, the policy will be treated as inforce and the benefits will be paid after deduction of the said unpaid premium and also the unpaid premium/s falling due before the next policy anniversary.

If premium is not paid before the expiry of the days of grace, the Policy lapses.

If the Policy has not lapsed and the claim is admitted in case of death under the policy where the mode of payment of premium is other than yearly, unpaid premium(s), if any, falling due before the next policy anniversary shall be deducted from the claim amount.

The above grace period will also apply to Accident Benefit rider premiums as the rider premiums are to be paid along with premium for the basic policy.

8. REBATES: The rebates for basic plan are as under:

Mode Rebate: Yearly mode Half-yearly mode Quarterly and monthly mode

: 2% of tabular premium : 1% of tabular premium :NIL

High Basic Sum Assured Rebate: Basic Sum Assured 75,000 to 1,45,000 1,50,000 to 2,00,000

Rebate {Rs.) :Nil : 1.50 %o Basic Sum Assured

9. CORPORATION EMPLOYEES' INSURANCE SCHEME (CEIS) REBATE: Policy completed under Corporation Employees' Insurance Scheme (CEIS) will be eligible for the CEIS rebate as a percentage of tabular premium for the basic plan as well as on LIC's Accident Benefit rider premium, if opted for, at the following rates provided policy is not taken through any intermediary such as Agent/ Corporate Agent/Broker/Direct Sales Executive etc.

Policy Term Percentage of tabular premium as well as AB rider premium

10 to 14 years 4% 15 years or more 7.5%

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10. COMMISSION PAYABLE TO INTERMEDIARIES & CREDIT TO DEVELOPMENT OFFICERS: a) Commission rates (as a percentage of premium net of taxes) during the policy term are as under:

Agents and Corporate Agents: Policy Term 1st Year 1 0 to 14 years 15%

15 years & above 18.75%

2nd & 3'd Year 5.5% 5.5%

Bonus Commission: 40% of 1st year commission.

Brokers: Policy Term 10 to 14 years 15 years & above

1st Year 16% 19.75%

2nd & 3'd Year 5% 5%

Subsequent Years 3.75% 3.75%

Subsequent Years 3.75% 3.75%

Bonus Commission: No bonus commission is payable to brokers.

b) Development Officer's Credit: Policy Term Credit (as a% of the first year premium net of taxes) 10 to 14 years 30%

15 years & above 60%

11. PAID-UP VALUE: If after atleast three full years' premium have been paid and any subsequent premiums be not duly paid, this policy shall not be wholly void, but shall subsist as a paid-up policy. The Basic Sum Assured under the policy shall be reduced to such a sum, called Paid-up Sum Assured, and shall bear the same ratio to the Basic Sum Assured as the number of premiums actually paid bears to the total number of premiums originally stipulated for in the policy i.e. Basic Sum Assured *(no. of premiums paid I Total number of premiums payable).

Such Paid-up policy shall thereafter be free from all liabilities for payment of the within mentioned premiums, but shall not be entitled to participate in future profits. This Paid-Up Sum Assured is payable on the expiry of policy term or on Life Assured's prior death.

Notwithstanding what is stated above, if atleast three full years' premiums have been paid in respect of this policy, and any subsequent premium be not duly paid, in the event of the death of the Life Assured within six months from the due date of first unpaid premium, Basic Sum Assured will be paid after deduction of (a) the premium or premiums unpaid for the basic policy with interest thereon upto the date of death, on the same terms as for revival of the Policy during such period and (b) the unpaid premiums for the basic policy falling due before the next Policy anniversary.

Notwithstanding what is stated above, if at least five full years' premiums have been paid in respect of this policy, and any subsequent premium be not duly paid, in the event of death of the Life Assured within 12 months from the first unpaid premium, Basic Sum Assured will be paid after deduction of (a) the premium or premiums unpaid for the basic policy with interest thereon upto the date of death, on the same terms as for revival of the Policy during such period and (b) the unpaid premium for the basic policy falling due before the next Policy anniversary. In addition to the above, Loyalty Addition, if any shall also be payable if death occurs after completion of five policy years.

These provisions do not apply to LIC's Accidental Benefit Rider as it does not acquire any paid up value and the rider benefit cease to apply, if policy is in lapsed condition.

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12. SURRENDER VALUE: The policy can be surrendered at any time during the policy term provided atleast three full years' premiums have been paid.

Guaranteed Surrender Value: The Guaranteed Surrender Value shall be a percentage of total premiums paid (net of taxes) excluding any extra premiums and premiums for riders, if opted for. This percentage will depend on the policy term and policy year in which the policy is surrendered and is enclosed as Annexure 3.

Special Surrender Value: The Corporation may, however, pay Special Surrender Value as applicable as on the date of surrender, provided the same is higher than Guaranteed Surrender Value. The Special Surrender Value will be the discounted value of Paid-up Sum Assured (as defined in Para 1 1 above). The discount factors shall be the surrender value factors as provided in Table-1 A of Special Surrender Values booklet used for Endowment Assurance plan, and will depend on the policy term and the duration elapsed since the commencement of the policy.

No Loyalty Addition is payable in case of surrender of the policies.

LIC's Accident Benefit Rider will not acquire any surrender value.

13. REVIVALS: If premiums are not paid within the grace period then the policy will lapse. A lapsed policy may be revived during the life time of the Life Assured, but within a period of 2 consecutive years from the date of first unpaid premium and before the date of maturity, on submission of proof of continued insurability to the satisfaction of the Corporation and the payment of all the arrears of premium together with interest (compounding half-yearly) at such rate as fixed by the Corporation from time to time.

Even though only standard lives shall be eligible at NB stage, on revival of a policy sub-standard lives shall also be considered based on underwriting decision.

The Corporation reserves the right to accept at original terms, accept at modified terms or decline the revival of a discontinued policy. The revival of discontinued policy shall take effect only after the same is approved by the Corporation and is specifically communicated to the Life Assured .

Revival of LIC's Accident Benefit Rider, if opted for, will be considered only along with revival of the Basic Policy, and not in isolation.

14. LOAN: Loan facility is available under this plan, after payment of premiums for at least 3 full years subject to following conditions: a) The maximum loan as a percentage of surrender value shall be 70% in case of inforce policies

and 60% in case of paid-up policies. b) The rate of interest to be charged for the loan amount would be determined from time to time by

the Corporation.

c) No foreclosure action under inforce policies shall be taken under this plan even if there is a

default in payment of loan interest. However, any loan outstanding alongwith interest shall be

recovered from the claim proceeds at the time of exit.

15. UNDERWRITING, AGE PROOF AND MEDICAL REQUIREMENTS : U & R department, Central Office, will issue instructions in this regard.

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16. SUICIDE CLAUSE: This policy shall be void a) If the Life Assured (whether sane or insane) commits suicide at any time within 12 months from

the date of commencement of risk, the Corporation will not entertain any claim under this policy except to the extent of 80% of the premiums paid excluding any taxes, extra premium and rider premiums, if any, provided the policy is inforce.

b) If the Life Assured (whether sane or insane) commits suicide within 12 months from date of revival, an amount which is higher of 80% of the premiums paid till the date of death (excluding any taxes, extra premium and rider premiums, if any) or the surrender value, shall be payable. The Corporation will not entertain any other claim under such policy.

17. FORFEITURE IN CERTAIN EVENTS: In case of fraud or misrepresentation, the policy shall be cancelled immediately by paying the surrender value, subject to the fraud or misrepresentation being established by the Corporation in accordance with Section 45 of the Insurance Act, 1938.

18. TAXES: Taxes including Service tax, if any, shall be as per the Tax laws and the rate of tax shall be as applicable from time to time.

The amount of tax as per the prevailing rates shall be payable by the Policyholder on premiums including extra premiums and rider premiums, if any. The amount of tax paid shall not be considered for the calculation of benefits payable under the plan.

The instructions regarding issues related to taxes will be issued by Finance & Accounts Department, Central office, separately, as applicable from time to time.

19. NORMAL REQUIREMENTS FOR CLAIM: The normal documents which the claimant shall submit while lodging the claim in case of death of the Life Assured shall be claim forms, as prescribed by the Corporation, accompanied with original policy document, NEFT mandate from the claimant for direct credit of the claim amount to the bank account, proof of title, proof of death, proof of accident, medical treatment prior to the death, School/College/employer's certificate, whichever is applicable, to the satisfaction of the Corporation. If age is not admitted under life policy, the proof of age of the Life Assured shall also be submitted.

Where the policy results into a maturity claim or in case of surrender of a policy, the Life Assured shalf submit the discharge form along with the original policy document, NEFT mandate from the claimant for direct credit of the claim amount to the bank account besides proof of age, if the age is not admitted earlier.

Instructions issued by CRM Department, Central Office, in this regard from time to time may be followed.

20. FREE LOOK PERIOD: If a Policyholder is not satisfied with the "Terms and Conditions" of the policy, he/she may return the policy stating the reasons thereof to the Corporation within 15 days from the date of receipt of the policy. The refund of premium to the Policyholder shall be subject to following deductions:

1. Stamp duty on policy; 2. Proportionate risk premium (in respect of Base Plan and Riders, if opted for) for the period on

cover as per C.O. Circular Ref: CO/ PD/ 39 dated 3151 December, 2013.

�·

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21. BACK-DATING INTEREST: The policies can be dated back within the same financial year. Back-dating interest as applicable at the time of completion of the policy (at the rate as fixed by the Corporation from time to time) will be charged for the period in excess of one month. However, if the policy is back dated to lean months, viz. April, May, July & August, interest is to be charged for period in excess of three months. The period upto 14 days is to be ignored and 15 days or more is to be rounded to a month for this calculation.

Any further instructions would be issued by Actuarial Department, Central Office, as applicable from time to time.

22. POLICY STAMPING: Policy stamping charges will be 20 paise per thousand of Basic Sum Assured & Accident Benefit Sum Assured, if Accident Benefit rider is opted for, under this Plan.

Any update in this regard to be issued by Legal Department, Central Office.

23. REINSURANCE: No reinsurance is required for policies taken under this plan.

24. ASSIGNMENTS/NOMINATIONS: It should be ensured that a nomination is made in the policy at the proposal stage as per Section 39 of Insurance Act, 1938. Further efforts should be made at the underwriting stage as well as on subsequent registration so as to eliminate the possibility of presence/involvement of moral hazard to a maximum extent. It should generally be insisted that the nominee should be spouse, children or very close relative of the Life Assured.

On a subsequent assignment as per Section 38 of Insurance Act, 1938 or change of nomination, the notice of assignment or change of nomination should be submitted for registration to the office of the Corporation, where the policy is serviced.

25. ACCOUNTING OF INCOME AND OUTGO: Instructions regarding the accounting procedure to be followed under the plan shall be issued separately by Finance & Accounts Department, Central office.

26. PROPOSAL FORM : Specimen proposal forms to be used under this plan are enclosed as Annexure- 4.

27. POLICY DOCUMENT: The specimen Policy Document will be sent by the Corporate Communications Department, Central Office.

28. DISCLOSURES: At the time of sale, a client specific Benefit Illustration shall be provided to the Policyholder. Such Benefit Illustration shall be signed by both the prospective policyholder and intermediary and shall form part of the policy document.

Separate instructions shall be issued by Marketing Department, Central Office, in this regard.

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LIC's Jeevan Rakshak (Plan no. 827) I L Annexure -1

Tabular Annual Premium rates for Rs. 1000 Basic Sum Assured

Policy Term �

10 11 12 13 14 15 16 17 18 19 20

8 85.90 76.20 68.20 61.55 55.90 51.70 47.45 43.75 40.50 37.70 35.15

9 85.90 76.20 68.20 61.55 55.90 51.70 47.45 43.75 40.55 37.70 35.15

10 85.90 76.20 68.25 61.55 55.95 5170 47.45 43.80 40.55 37.70 35.20

11 85.95 76.25 68.25 61.60 55.95 51.75 47.50 43.80 40.60 37.75 35.25

12 85.95 76.30 68.30 61.65 56.00 51.80 47.55 43.85 40.65 37.80 35.25

13 86.00 76.30 68.35 61.70 56.05 51.80 47.60 43.90 40.65 37.85 35.30

14 86.05 76.35 68.40 61.75 56.10 51.85 47.65 43.95 40.70 37.85 35.35

15 86.10 76.40 68.45 61.75 56.15 51.90 47.65 44.00 40.75 37.90 35.40

16 86.15 76.45 68.50 61.80 56.15 51.95 47.70 44.00 40.80 37.95 35.45

17 86.20 76.50 68.50 61.85 56.20 52.00 47.75 44.05 40.85 38.00 35.45

18 86.20 76.50 68.55 61.85 56.25 52.00 47.75 44.10 40.85 38.00 35.50

19 86.25 76.55 68.55 61.90 56.25 52.05 47.80 44.10 40.90 38.05 35.50

20 86.25 76.55 68.60 61.90 56.25 52.05 47.80 44.15 40.90 38.05 35.55

21 86.25 76.55 68.60 61.95 56.30 52.05 47.85 44.15 40.90 38.10 35.55

22 86.30 76.60 68.60 61.95 56.30 52.10 47.85 44.15 40.95 38.10 35.60

23 86.30 76.60 68.60 61.95 56.30 52.10 47.85 44.20 40.95 38.10 35.60

24 86.30 76.60 68.65 61.95 56.35 52.10 47.90 44.20 41.00 38.15 35.65

25 86.30 76.60 68.65 62.00 56.35 52.15 47.90 44.25 41.00 38.20 35.65

26 86.35 76.65 68.65 62.00 56.40 52.15 47.95 44.25 41.05 38.20 35.70

27 86.35 76.65 68.70 62.05 56.40 52.20 47.95 44.30 41.10 38.25 35.75

28 86.35 76.70 68.70 62.05 56.45 52.25 48.00 44.35 41.15 38.30 35.80

29 86.40 76.70 68.75 62.10 56.50 52.30 48.05 44.40 41.20 38.35 35.90

30 86.45 76.75 68.80 62.15 56.50 52.35 48.10 44.45 41.25 38.45 35.95

31 86.45 76.80 68.85 62.20 56.60 52.40 48.20 44.55 41.35 38.55 36.05

32 86.50 76.85 68.90 62.25 56.65 52.45 48.25 44.60 41.45 38.65 36.15

33 86.60 76.90 68.95 62.35 56.75 52.55 48.35 44.70 41.55 38.75 36.30

t 34 86.65 77.00 69.05 62.40 56.80 52.65 48.45 44.85 41.65 38.90 36.45

35 86.75 77.05 69.15 62.50 56.95 52.75 48.60 44.95 41.80 39.05 36.60

Q) 36 86.80 77.15 69.25 62.65 57.05 52.90 48.75 45.10 41.95 39.20 36.80 0>

37 86.95 77.30 69.35 62.75 57.20 53.05 48.90 45.30 42.15 39.40 37.00 <( 38 87.05 77.40 69.50 62.90 57.35 53.25 49.10 45.50 42.35 39.65 37.20

39 87.20 77.55 69.70 63.10 57.55 53.45 49.30 45.75 42.60 39.90 37.50

40 87.35 77.75 69.85 63.30 57.75 53.70 49.55 46.00 42.90 40.15 37.80

41 87.55 77.95 70.10 63.55 58.00 53.95 49.85 46.30 43.20 40.50 38.10

42 87.75 78.20 70.35 63.80 58.30 54.25 50.15 46.60 43.50 40.85 38.45

43 88.00 78.45 70.60 64.10 58.60 54.55 50.50 46.95 43.90 41.20 38.85

44 88.30 78.75 70.90 64.40 58.95 54.90 50.85 47.35 44.30 41.65 39.30

45 88.60 79.10 7 1 .25 64.75 59.30 55.30 51.25 47.75 44.75 42.10 39.75

46 88.95 79.45 71.65 65.15 59.70 55.75 51.70 48.25 45.20 42.60 40.25

47 89.35 79.85 72.05 65.60 60.15 56.20 52.20 48.75 45.70 43.10 40.80

48 89.75 80.25 72.50 66.05 60.65 56.70 52.70 49.25 46.30 43.70 41.40

49 90.20 80.70 73.00 66.55 61.15 57.25 53.25 49.85 46.85 44.30 42.05

50 90.65 81.20 73.50 67.05 61.70 57.80 53.85 50.45 47.50 44.95 42.70

51 91.15 81.70 74.00 67.60 62.25 58.40 54.45 51.10 48.15 45.65 -

52 91.65 82.25 74.55 68.20 62.85 59.05 55.15 51.75 48.85 - -

53 92.20 82.80 75.15 68.80 63.50 59.70 55.85 52.50 - - -

54 92.75 83.40 75.75 69.45 64.15 60.45 56.55 - - - -

55 93.35 84.00 76.40 70.10 64.85 61.20 - - - - -

Note: ·The above premium rate is exclusive of Service Tax

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LIC's Jeevan Rakshak (Plan no. 827) I I Annexure· 2 I Class • I extra premium rates oer Rs. 1000 Basic Sum Assured

Outstanding duration on revival -+

<•2 3 4 s 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

8 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15

9 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 010 0.15 0.15 015 0 1 5 0.15 0.15 0.15 0.15 015

10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.15 0.15 0.15 0.15 0 15 0 15 0.15 0.15 0 15 0.15

11 0.10 0.10 0.10 0.10 0 10 0.10 0.10 0.10 0 15 0.15 0.15 0.15 0 15 0 15 0.15 0.15 0.15 0.15 0.20

12 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0 .15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.20 0.20 0.20 0.20

13 0.10 0.10 0.10 0.10 0.10 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20

14 0.10 0.10 0.10 0.15 0.15 0.15 0.15 0 15 0 15 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20

15 0.10 0.10 0.15 0.15 0.15 0.15 0.15 015 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0. 20 020 0.20

16 0.10 0.10 0.15 0.15 0.15 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 0.25

17 0.10 0.15 0.15 0.15 0 15 0 15 0.20 0.20 0.20 0 20 0 20 0.20 0.20 0.20 0.20 0.25 0.25 025 0.25

18 0 10 0.15 0.15 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25

19 0.10 0.15 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25

20 0.10 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 025 0 25 0.25 0.25 0 25 0.25

21 0 15 0.1 5 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0 .25 0.25 025 0.25 0.25

22 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25

23 0.15 015 0.20 020 0 20 0 20 0.20 0 20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.30

24 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0 25 0.30 030 -

25 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.30 0.30 0.30

26 0.15 0 15 0.20 0.20 020 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.30 0.30 0.30 0.30

27 0 15 0.15 0.20 0.20 0 20 0.20 0.20 0.25 0 25 0 25 0.25 0.25 0.25 0.25 0.30 0.30 0.30 0.30 0.30

28 0.15 0.15 0.20 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0.30 0 30 0.30 0.30 0.30 0 35

29 0.15 0.15 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0.30 0 30 0.30 0.30 0.30 0.35 0.35

30 0 15 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.25 0 .30 030 030 0.30 0.35 0.35 035 035

31 0.15 0.20 0.20 0.20 0.20 0.25 0.25 0.25 0.25 0.25 0.30 0.30 0.30 0.30 0.35 0.35 0.35 0.35 0.40

32 0 15 0.20 0.20 0.20 0.25 0.25 0 25 0.25 0.30 0.30 0.30 0.30 0.30 0 35 0.35 0.35 0.40 040 0.40

33 0 15 0.20 0.20 0.25 025 0.25 0.25 0.30 0.30 030 0 30 035 0.35 0.35 040 040 040 045 045

34 0.15 0.20 0.25 0.25 0.25 0.25 0.30 0.30 0.30 0.30 0.35 0.35 0 35 0 4 0 0 40 0.40 0.45 0.45 0.50

35 0.15 0.20 0.25 0.25 0.25 0.30 0.30 0.30 0.35 0.35 0.35 0.35 0 40 0 40 0.45 0.45 0.50 0.50 0 50

3G 0.20 0.25 0.25 0.25 0.30 0.30 0.30 0.35 C.35 0.3 5 0.40 0.40 0.40 0.45 0.45 0.50 0.50 055 0 55

37 0.20 0.25 0.25 0.30 0.30 0.30 0.35 0.35 0.40 0.40 0.40 0.45 0.45 0.50 0.50 0.55 0.55 0.60 0.60

38 0.20 0.25 0.30 0 30 0 35 0 35 0.35 0.40 0.40 0.45 0.45 0.50 0.50 0.55 0.55 0.60 0.60 0.65 0.70

39 0 20 0.30 0.30 0.35 0.35 0.40 0.40 0.40 0.45 0 45 050 0 5 0 0.55 0.60 0.60 0 6 5 0 70 0.70 0.75

40 0.25 0.30 0.35 0.35 0.40 0.40 0.45 045 0.50 0.50 0.55 0.55 0.60 0.65 0.70 0.70 0.75 0.80 0.80

41 0 25 0.30 0.35 0.40 0.40 0.45 0.50 0.50 0.55 0.5 5 0.60 0.65 0.65 0.70 0.75 0.80 0.85 0.85 0.90

42 0 25 035 0.40 0.45 0.45 0.50 0 .50 0 .55 0.60 0.65 0.65 0.70 0.75 0.80 0.85 0. 85 0 90 0.95 1 00

43 0.30 0.40 0.45 0.45 0.50 0.55 0.60 0.60 0.65 0.70 0.75 0.75 0.80 0 85 0.90 0.95 100 1.05 1.10

44 0.35 0.40 0.50 0.50 0.55 0.60 0.65 0.70 0.75 0.75 0.60 0.85 0.90 0.95 1.00 1.05 1.10 115 1.20

45 0.35 0.45 0.55 0.60 0.65 0.65 0.70 0. 75 0.80 0.85 0.90 0.95 1.00 1.05 1 . 10 1.15 1.20 1.30 1,35

46 0.40 0.50 0.60 0.65 0.70 0.75 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.20 1.25 1.30 135 1.40 1.45

47 0 4 5 0 60 0 65 0.70 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20 1.30 1.35 1.40 1.50 1.55 1.60

48 0.50 0.65 0.75 0.80 0.85 0.90 1.00 1.05 1.10 1.15 1.20 1.30 1.35 1.45 1.50 1.55 1 65 1.70 1 75

49 0.55 0.70 0.80 0.90 0.95 1.00 1.10 1.15 1.20 1.30 1.35 1.40 1 50 1 55 1.65 1.70 1.80 1.85 1.90

50 0.60 0.80 0.90 1.00 1.05 1. 1 5 1.20 1 25 1 35 1.40 1 50 1.55 1.60 170 1.60 1.85 1.95 2.00 2.10

J 51 0 65 0.90 1.00 1.10 1.15 1.25 1.30 1.40 1.45 1.55 1.60 1.70 1.75 1.90 1.95 2.05 2.10 2.20

-.; 52 0.75 0.95 1.10 1 20 1 30 1.35 1.45 1.50 1.60 1.70 1.75 1 85 1 95 2 05 2.15 220 2.30

.:::: >

53 0.60 1.05 1.20 1.30 140 1.50 1.55 1.65 1.75 1.85 1.90 2.00 2.10 2.25 2.35 2.40

1.:! 54 0.90 1.15 130 1.40 1.50 1.60 1.70 1.80 1.90 2.00 2 . 1 0 2. 20 230 2.45 2 . 5 5 . .... .. 55 0.95 1.25 1.40 1.55 1.65 1.75 1.85 1.95 2.05 2.15 2.25 2.35 2.45 2.65 . . <I> Ol 56 1.05 1.35

<{ 1.55 1.65 1.80 1.90 2.00 2 10 2.25 2.35 2.45 2.55 2 70 - -

57 1.10 1.45 1.65 1.80 1.95 2.05 2.15 2.30 2.40 2.55 2.65 2.80 - .

58 1 .20 1.60 1.80 1 95 2 10 2.20 2.35 2.50 2.60 2.75 2.90 . . .

59 1.30 1 70 1.95 2.10 2.25 2.40 2.55 2 70 2.85 3.00 . . .

60 1.40 1.85 2.10 2.25 2.45 2.60 2.75 2.90 3.05 . . . .

61 1.50 2.00 2.25 2.45 2.65 2.80 3.00 3.15 . - .

62 1.65 2.15 2.45 2.65 285 3.05 3.25 . . . . . -

63 1.80 2.35 2.65 2.90 3.10 3.35 . . .

64 1.90 2.55 2.90 3 15 3 40 . .

6 5 210 2.75 3.15 3.45 - . . . . .

66 2.30 3.00 3.40 - . -

67 2.50 3.25 . . . .

68 2.70 . - . . . . - .

69 . . . . - .

Noto: The above premium ra1es are exclusive of Serv•ce Tax

VAEM

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VAEM

of 7

LIFE INSURANCE CORPORATION OF INDIA Annexure - 4

(Established by the Life Insurance Corporation Act, 1956)

PROPOSAL FORM FOR LIC’s JEEVAN RAKSHAK (UIN: 512N289V01)

(ON OWN LIFE)

(This form is not to be used for proposals on the lives of minors)

To be filled in by agent

Divisional Office Branch Office DO/CLIA Code No

____________ ___________ ________________

Agent's / FSE's/DSE's /Sup Agent's Name: ___________

Agent's /FSE's/DSE's

/Sup. Agent’s Code No License No Date of expiry

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

FOR OFFICE USE ONLY :

Proposal no :

Amt. of Deposit :

B.O.C No:

Date :

(All answers to be filled in legibly. Answers must be given in words. Stroke of the pen or dot or dashes will not be

accepted as replies).

1. A)Name the proposer in full (IN BLOCK LETTERS)

(First Name) (Middle Name) (Surname)

Mr/Mrs/Miss....................................................................................................... B) Sex: (M/F) ..................

C) Address for correspondence.......................................................................................................................

......................................................................................................................

D) Residential Address, if different from above................................................................................................

......................................................................................................................

E) Tel.No. (STD code): Res: Off: Mobile:

2. Plan & Term:........... Sum Proposed (Rs.):.................. Amount of deposit:..............BOC No & Date..........

Mode (Yly, Hly, Qly, Mly or SSS) ..............

If Policy is to be dated back, indicate date:..................

Accident Benefit Sum Proposed (if required)(Rs.):..................

Total Accident Benefit Sum Assured under all previous policies: ..........................

PHOTO

Inward No. Date

VAEM

of 7

3. Date of birth......................Age (nearer birthday)............, Place of Birth...................Nationality....................

Nature of Age proof submitted.......................

4. Nominee's full name (Surname first) and address IN BLOCK LETTERS)..............................................

Age.................... Relationship to yourself...........................

If Nominee is a minor, appointee's full name and address

Age..................... Relationship to nominee................................Signature of appointee as token of consent

5. Present Occupation.........................Name of the Employer........................Nature of duties...................................

Educational Qualification......................... Annual Income..........................

6. Has a proposal on your life or an application for revival of a policy on your life made to this or any other Office

of the Corporation ever been

i) Withdrawn, Deferred, Dropped, Declined?-Yes / No .........., if yes, give details....................

ii) Accepted with extra premium or Lien?-Yes /No.........., if yes, give details....................

iii) Accepted on modified terms? -Yes /No.........., if yes, give details....................

7. Please give details of your previous insurance under this plan:

Sr. No. Policy No. Table &

Term

Basic Sum

Assured *

Date of

Commencem

ent

Whether

inforce for full

Sum Assured

If not give due date

of last premium

paid or date of

surrender

(*) – The total Sum Assured under all policies (including Basic Sum Assured under this proposal) of an

individual under this plan is Rs. 2 lacs only.

8. Health Details of the Life Assured

A) Height-----------------------cms Weight......................................kgs

B) Do you or have you ever used-

i) Alcoholic drinks -Yes /No ...............

ii) Narcotics -Yes / No ...............

iii) Any other drugs-Yes/No...............

iv) Tobacco in any form-Yes / No...............

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of 7

If yes, frequency/quantity consumed /day............................................

If reply to any of the Questions from ‘C’ to ‘H’ below is “yes”, please give full details. If space is

inadequate, use separate sheet

C) During the last five years did you ever consult a Medical Practitioner for any ailment requiring treatment

for more than a week -Yes / No

D) Are you currently taking, or have you previously taken, any medication or treatment for a continuous

period of more than 14 days for any condition other than for minor coughs, cold, flu, typhoid? -Yes / No

E) (i) Did you ever have any accident or injury? Yes /No

(ii) Have you ever had an Electrocardiogram, X-ray or screening, Blood, Urine or stool examination? Yes

/No

(iii) Have you ever been admitted to any hospital nursing home for general check -up, observation,

treatment or operation?-Yes /No

F) Do you have any congenital defect, physical deformity or handicap? Yes /No

G) Have you currently been advised to undergo any medical investigation or are you awaiting results of any

investigation (other than routine health check) at this point-Yes/No

H) Have you ever been diagnosed with, treated for, or advised to seek treatment from any of the following

conditions? Please tick to indicate presence of any of the following conditions.

Hypertension / high blood pressure -Yes/No Diabetes/High blood sugar/sugar in urine-Yes / no

Cancer, Leprosy, rheumatism, tumor, growth or cyst

of any kind -Yes /No

Chest pain/heart attack or any other heart

disease/problem -Yes /No

Cancer, tumor, growth or cyst of any kind, Leprosy,

rheumatism -Yes /No

Tuberculosis or any other lung disorder-Yes/No

Hernia, hydrocele, varicocele, fistula, varicose veins,

skin eruption, filariasis, goitre, gonorrhoea, syphilis,

or any other venereal disease-Yes/No

Any disease of the ear, nose, throat or eyes,

including defective sight or hearing and discharge

from the ears-Yes/No

Any problems of digestive system like ulcer, colitis,

etc -Yes/No

Liver or gall bladder problems/jaundice/Hepatitis

B or C / Stomach/ pancreas/spleen- Yes/No

Any blood disorder (e.g. Haemophilia, thalassaemia )

-Yes/No

HIV Infection/AIDS or positive test for HIV-

Yes/No

Nervous, psychiatric, mental disorder or any other

disease of brain-Yes/No

Stroke / paralysis/ epilepsy/ fits of any kind-

Yes/No

9. FOR FEMALE APPLICANTS ONLY:

Date of last menstruation---------------- Date of Last Delivery----------------

Have you ever had any abortion or miscarriage or ceasarian section, if yes, give details....................

Have you suffered from any gynecological problem or illness related to breasts, uterus or ovary? If yes, give

VAEM

of 7

details. ...................

Are you pregnant now?

10. Are you at present in good health?

11. Have you understood fully the terms & conditions of the plan you propose to take?

12. Please provide the following information to help us serve you better.

a. Bank Account details:

b. Type of Account-Saving / Current:

c. 9 Digit MICR:

d. Name and Address of your bank:

e. IFS Code:

f. RTGS Code :

g. Name of Repository and electronic Insurance Account No. (if you have this account):

Name of Repository: electronic Insurance Account No.:

13. Attach a photocopy of cancelled cheque with the form.

DECLARATION BY THE PROPOSER (Life to be assured)

I ___________________________________________the person whose life is herein being proposed to be assured,

do hereby declare that the forgoing statements and answers have been given by me after fully understanding the

questions and the same are true and complete in every particular and that I have not withheld any information and I

do hereby agree and declare that these statements and this declaration shall be the basis of the contract of assurance

between me and the Life Insurance Corporation of India. I further agree that if after the date of submission of the

proposal but before the issue of First Premium Receipt (i) any change in the occupation of the life to be assured or

any adverse circumstances connected with the financial position or general health of the life to be assured or that of

any members of family of the life to be assured occurs or (ii) if a proposal for assurance or any application for

revival of a policy on the life to be assured made to any office of the Corporation has been withdrawn or dropped,

deferred or accepted at an increased premium or subject to a lien or on terms other then as proposed I shall forthwith

intimate the same to the Corporation in writing to reconsider the terms of acceptance of assurance. And if any such

omission on my part or any untrue averment contained therein is established by the Corporation in accordance with

Section 45 of the Insurance Act, 1938, the said contract shall be absolutely null and void and all claims to any

benefit in virtue hereof shall cease immediately by paying the Surrender Value.

Not-withstanding 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

employment on the grounds of secrecy, I , my heirs, executors, administrators and assignees or any other person or

persons, having interest of any kind whatsoever in the policy contract issued to me, hereby agrees that such

authority , having such knowledge or information, shall at any time be at liberty to divulge any such knowledge or

information to the Corporation. I authorize LIC of India to take my personal details of Aadhaar from the Unique

VAEM

of 7

Identification Authority of India (UIDAI) / National Population Register (NPR)

Dated at ……………………………… on the ……………………….day of ………………..20

Signature of witness ………………………… Signature/Thumb impression of the life to be assured……………

Name & Address (of Witness) Name of the life to be assured …………………………..

…………………………………………………

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

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

1. Declaration by the person filling in the form (in case form is filled up / signed in a language different from that

of the proposal form)

“I hereby declare that I have fully explained the above questions to the proposer and I have truthfully recorded

the answers given by the Proposer.”

Name of the Declarant

………………………………….

Address of the Declarant …………………………………….

…………………………………. (Signature of the Declarant)

………………………………….

…..………………………………

I certify that the contents of the form and documents have been fully explained to me by (Name, Designation,

and Occupation) Mr./Mrs._________________________ and I have understood the significance of the proposed

contract.

…………………………………….

(Signature or thumb impression of the proposer)

2. In case the proposer is illiterate, his/her thumb impression should be attested by a person of standing whose

identity can easily be established, but unconnected with the Corporation and this declaration should be made by

him.

“I hereby declare that I have fully explained the above questions and contents of the proposal form to the

proposer in ………………… language and that the proposer has affixed his/her thumb impression above after

fully understanding the contents thereof.”


………………………………….

Address of the Declarant

……………………………… ……………………………………..

……………………………… Signature

………………………………

VAEM

of 7

SUMMARY OF SECTION 45 OF INSURANCE ACT, 1938

No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be called in

question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a

medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was

inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which

it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at

the time of making it that statement was false or that it suppressed facts which it was material to disclose.

Note: “Material” shall mean and include all important, essential and relevant information in the context of

underwriting the risk to be covered by the Corporation.

INSURANCE ACT 1938 UNDER SECTION 41

1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or

renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the

whole or part of the commission payable or any rebate of the Premium shown on the policy nor shall any person

taking out renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance

with the published prospectus or tables of the insurer. Provided that acceptance by an insurance agent of

commission with a policy of life insurance taken out by himself on his own life shall not be deemed to acceptance

of a rebate of premium within the meaning of sub-section if at any time of such acceptance the insurance agent

satisfies the prescribed conditions establishing that he is a bonafide insurance agent employed by the insurer.

2) Any person making default in complying with the provision of this section shall be punishable with fine which

may extend to five hundred rupees.

VAEM

of 7

LIFE INSURANCE CORPORATION OF INDIA


AGENT'S CONFIDENTIAL REPORT FOR LIC’S JEEVAN RAKSHAK PLAN (UIN: 512N289V01)

Divisional office.........Branch Code No................................ Proposal No............................

Name of the agent.................... Agency Code No...................License No ............................

and Date of license expiry......................

Name of the proposer..................Age...............Occupation.............Annual Income.............

1. Give marks of identification.......................................................

2. How long have you known the proposer?...........................................

3. Does he appear to be of the age stated in the proposal?.............................................

4. Does he/she appear to be in good health and free from any disease / deformity?..................................

5. Height of the proposer........................cms Weight of the proposer..............................kgs

6. Do you have any knowledge of his/her having suffered from any illness or injury or undergone any

operation, hospitalisation or medical investigations, if yes give details.........................................................

7. Are you aware of anything in the occupation,financial or social position of the proposer,his /her personal

habits or any other circumstances which are likely to add to the risk?......................................................

8. Do you recommend acceptance of the proposal?.................................................

9. Have you explained fully the terms and conditions of the plan to the proposer?............................................

10. Are you satisfied that the life proposed and /or proposer is not connected with any terrorist

activities?..................................................

I hereby declare that the foregoing statements are true to the best of my belief.

Dated at.............................................

Date................................................. Signature of Agent

(To be completed by the DO/CLIA/SBA/ABM/BM/Sr. BM)

I am satisfied with the identity of the party and on the basis of my independent enquiries, I hereby declare that the

foregoing statements are true and correct to the best of my knowledge and behalf.

Dated at......................Date........................

Name & Designation/Standing (No. of years) .............................. Signature

VAEM

of 7

LIFE INSURANCE CORPORATION OF INDIA Annexure - 4


PROPOSAL FORM FOR LIC’s JEEVAN RAKSHAK (UIN: 512N289V01)

(ON THE LIFE OF ANOTHER PERSON)

(This form is to be used for proposals on the lives of both Minors and Adults)

To be filled in by agent

Divisional Office Branch Office DO/CLIA Code No

____________ ___________ ________________

Agent's / FSE's/DSE's /Sup Agent's Name: ___________

Agent's /FSE's/DSE's

/Sup. Agent’s Code No License No Date of expiry

__________________ __________ _____________

FOR OFFICE USE ONLY :

Proposal no :

Amt. of Deposit :

B.O.C No:

Date :

(All answers to be filled in legibly. Answers must be given in words. Stroke of the pen or dot or dashes will not be

accepted as replies).

1. A) Name the proposer in full (IN BLOCK LETTERS)


Mr/Mrs/Miss....................................................................................................... B) Sex: (M/F) ..................

C) Address for correspondence.......................................................................................................................

......................................................................................................................

D) Residential Address, if different from above................................................................................................

......................................................................................................................

E) Tel.No. (STD code): Res: Off: Mobile:

F) Occupation:

2. Full Name of the Life to be Assured (IN BLOCK LETTERS).


Mr/Mrs/Miss.......................................................................................................

Inward No. Date

PHOTO

VAEM

of 7

Mode (Yly, Hly, Qly, Mly or SSS) ..............

If Policy is to be dated back, indicate date:..................

3. Plan & Term:................Sum Proposed(Rs.):..................Amount of deposit:..............BOC No & Date..........

Accident Benefit Sum Proposed (if required)(Rs.):..................

4. Date of birth............................Age (nearer birthday).................

Place of Birth...................Nationality..................... Nature of Age proof submitted.......................

5. A) Present Occupation of the life to be assured............................................

B) Standard in which studying................................................

6. Has a proposal on your life or an application for revival of a policy on your life made to this or any other

Office of the Corporation ever been

i) Withdrawn, Deferred, Dropped, Declined?-Yes / No.........., if yes, give details....................

ii) Accepted with extra premium or Lien?-Yes /No.........., if yes, give details....................

iii) Accepted on modified terms? -Yes /No.........., if yes, give details....................

7. Please give details of your previous insurance under this plan:

Sr. No. Policy

No.

Table &

Term

Basic Sum

Assured *

Date of

Commencement

Whether

inforce for

full Sum

Assured

If not give due date

of last premium paid

or date of surrender

(*) – The total Sum Assured under all policies (including Basic Sum Assured under this proposal) of

an individual under this plan is Rs. 2 lacs only.

8. Health Details of the Life Assured

A) Height-----------------------cms Weight......................................kgs

B) Do you or have you ever used-

i) Alcoholic drinks -Yes /No

ii) Narcotics -Yes / No

iii) Any other drugs-Yes/No

iv) Tobacco in any form-Yes / No

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If yes, frequency/quantity consumed /day............................................

If reply to any of the Questions from ‘C’ to ‘H’ below is “yes”, please give full details. If space is

inadequate, use separate sheet

C) During the last five years did you ever consult a Medical Practitioner for any ailment requiring treatment

for more than a week -Yes / No

D) Are you currently taking, or have you previously taken, any medication or treatment for a continuous

period of more than 14 days for any condition other than for minor coughs, cold, flu, typhoid? -Yes / No

E) (i) Did you ever have any accident or injury? Yes /No

(ii) Have you ever had an Electrocardiogram, X-ray or screening, Blood, Urine or stool examination? Yes

/No

(iii) Have you ever been admitted to any hospital nursing home for general check -up, observation,

treatment or operation?-Yes /No

F) Do you have any congenital defect, physical deformity or handicap? Yes /No

G)Have you currently been advised to undergo any medical investigation or are you awaiting results of any

investigation (other than routine health check) at this point-Yes/No

H) Have you ever been diagnosed with, treated for, or advised to seek treatment from any of the following

conditions? Please tick to indicate presence of any of the following conditions:

Hypertension / high blood pressure -Yes/No Diabetes/High blood sugar/sugar in urine-Yes / no

Cancer, tumor, growth or cyst of any kind, Leprosy,

rheumatism -Yes /No

Chest pain/heart attack or any other heart

disease/problem -Yes /No

Kidney problems or disease of the reproductive

organs-Yes/No

Tuberculosis or any other lung disorder-Yes/No

Hernia, hydrocele, varicocele, fistula, varicose veins,

skin eruption, filariasis, goitre, gonorrhoea, syphilis,

or any other venereal disease-Yes/No

Any disease of the ear, nose, throat or eyes,

including defective sight or hearing and discharge

from the ears-Yes/No

Any problems of digestive system like ulcer, colitis,

etc -Yes/No

Liver or gall bladder problems/jaundice/Hepatitis

B or C / Stomach/ pancreas/spleen- Yes/No

Any blood disorder (e.g. Haemophilia, thalassaemia )

-Yes/No

HIV Infection/AIDS or positive test for HIV-

Yes/No

Nervous, psychiatric, mental disorder or any other

disease of brain-Yes/No

Stroke / paralysis/ epilepsy/ fits of any kind-

Yes/No

9. FOR FEMALE APPLICANTS ONLY:

Date of last menstruation---------------- Date of Last Delivery----------------

Have you ever had any abortion or miscarriage or ceasarian section, if yes, give details....................

Have you suffered from any gynecological problem or illness related to breasts, uterus or ovary? If yes, give

details. ...................

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Are you pregnant now?

10. Are you at present in good health?

11. Have you understood fully the terms & conditions of the plan you propose to take?

12. Please provide the following information to help us serve you better.

a. Bank Account details:

b. Type of Account-Saving / Current:

c. 9 Digit MICR:

d. Name and Address of your bank:

e. IFS Code:

f. RTGS Code:

g. Name of Repository and electronic Insurance Account No. (if you have this account):

Name of Repository: electronic Insurance Account No.:

13. Attach a photocopy of cancelled cheque with the form.

DECLARATION BY THE LIFE ASSURED / PROPOSER IF THE LIFE TO BE ASSURED IS A MINOR

I _____________________( name of the Life Assured, if major / proposer if the Life Assured is a minor) do hereby

declare that the statements and answers under heading 7 to 12 of the proposal form have been given by me after

fully understanding the questions and the same are true and complete in every particular and that I have not

withheld any information and I do hereby agree and declare that these statements and this declaration shall be the

basis of the contract of assurance between me and the Life Insurance Corporation of India and that if any untrue

averment contained therein is established by the Corporation in accordance with Section 45 of the Insurance Act,

1938, the said contract shall be absolutely null and void and all claims to any benefit in virtue hereof shall cease

immediately by paying the Surrender Value.

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

employment on the grounds of secrecy, I, my heirs, executors, administrators and assignees or any other person or

persons, having interest of any kind whatsoever in the policy contract issued to me, hereby agrees that such

authority, having such knowledge or information, shall at any time be at liberty to divulge any such knowledge or

information to the Corporation.


Signature of Witness ……………………Signature or Thumb impression of the life to be assured…………………

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Name and address of Witness

………………………………

……………………………… Signature of the Proposer (if the life assured is Minor)…………………

………………………………

DECLARATION BY THE PROPOSER

I _____________________( name of the proposer) do hereby declare that the statements and answers under heading

1 to 6 of the proposal form have been given by me after fully understanding the questions and the same are true and

complete in every particular and that I have not withheld any information and I do hereby agree and declare that

these statements and this declaration along with the statements made by the life to be assured under heading 7 to 12

of the proposal form and declaration relative thereto shall be the basis of the contract of assurance between me and

the Life Insurance Corporation of India. I further agree that if after the date of submission of the proposal but before

the issue of First Premium Receipt (i) any change in the occupation of the life to be assured or any adverse

circumstances connected with the financial position or general health of the life to be assured or that of any

members of family of the life to be assured occurs or (ii) if a proposal for assurance or any application for revival of

a policy on the life to be assured made to any office of the Corporation has been withdrawn or dropped, deferred or

accepted at an increased premium or subject to a lien or on terms other then as proposed I shall forthwith intimate

the same to the Corporation in writing to reconsider the terms of acceptance of assurance. However, if any such

omission on my part or any untrue averment contained therein is established by the Corporation in accordance with

Section 45 of the Insurance Act, 1938, the said contract shall be absolutely null and void and all claims to any

benefit in virtue hereof shall cease immediately by paying the Surrender Value.

I authorize LIC of India to take my personal details of Aadhaar from the Unique Identification Authority of India

(UIDAI) / National Population Register (NPR)


Signature of witness ………………………… Signature or thumb impression of the Proposer

Name and address of witness

………………………………

………………………………

1. Declaration by the person filling in the form (in case form is filled up / signed in a language different from that

of the proposal form)

“I hereby declare that I have fully explained the above questions to the proposer / Life Assured and I have

truthfully recorded the answers given by the Proposer / Life Assured.”


………………………………….

Address of the Declarant …………………………………….

…………………………………. (Signature of the Declarant)

………………………………….

…..………………………………

I certify that the contents of the form and documents have been fully explained to me by (Name, Designation,

and Occupation) Mr./Mrs._________________________ and I have understood the significance of the proposed

contract.

…………………………………….

(Signature or thumb impression of the proposer)

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2. In case the proposer and / or Life Assured is / are illiterate the thumb impression of the proposer / Life Assured

should be attested by a person of standing whose identity can easily be established, but unconnected with the

Corporation and this declaration should be made by him.

“I hereby declare that I have fully explained the above questions and contents of the proposal form to the

proposer / Life Assured in ………………… language and that the proposer / Life Assured has affixed his/her

thumb impression above after fully understanding the contents thereof.”


………………………………….

Address of the Declarant

……………………………… ……………………………………..

……………………………… Signature

………………………………

SUMMARY OF SECTION 45 OF INSURANCE ACT, 1938

No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be called in

question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a

medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was

inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which

it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at

the time of making it that statement was false or that it suppressed facts which it was material to disclose.

Note: “Material” shall mean and include all important, essential and relevant information in the context of

underwriting the risk to be covered by the Corporation.

INSURANCE ACT 1938 UNDER SECTION 41

1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or

renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the

whole or part of the commission payable or any rebate of the Premium shown on the policy nor shall any person

taking out renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance

with the published prospectus or tables of the insurer. Provided that acceptance by an insurance agent of

commission with a policy of life insurance taken out by himself on his own life shall not be deemed to acceptance

of a rebate of premium within the meaning of sub-section if at any time of such acceptance the insurance agent

satisfies the prescribed conditions establishing that he is a bonafide insurance agent employed by the insurer.

2) Any person making default in complying with the provision of this section shall be punishable with fine which

may extend to five hundred rupees.

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LIFE INSURANCE CORPORATION OF INDIA


AGENT'S CONFIDENTIAL REPORT FOR LIC’s JEEVAN RAKSHAK PLAN (UIN: 512N289V01)

Divisional office.........Branch Code No................................ Proposal No............................

Name of the agent.................... Agency Code No...................License No. ...................

and Date of license expiry......................

Name of the proposer..................Age...............Occupation.............Annual Income.............

1. Give marks of identification.......................................................

2. How long have you known the proposer?...........................................

3. Does he appear to be of the age stated in the proposal?.............................................

4. Does he/she appear to be in good health and free from any disease / deformity?..................................

5. Height of the proposer........................cms Weight of the proposer..............................kgs

6. Do you have any knowledge of his/her having suffered from any illness or injury or undergone any

operation , hospitalisation or medical investigations?...........................................................................

7. Are you aware of anything in the occupation,financial or social position of the proposer,his /her personal

habits or any other circumstances which are likely to add to the risk?......................................................

8. Do you recommend acceptance of the proposal?.................................................

9. Have you explained fully the terms and conditions of the plan to the proposer?............................................

10. Are you satisfied that the life proposed and /or proposer is not connected with any terrorist

activities?..................................................

I hereby declare that the foregoing statements are true to the best of my belief.

Dated at.............................................

Date................................................. Signature of agent

(To be completed by the DO/CLIA/SBA/ABM/BM/Sr. BM)

I am satisfied with the identity of the party and on the basis of my independent enquiries, I hereby declare that the

foregoing statements are true and correct to the best of my knowledge and behalf.

Dated at......................Date........................

Name & Designation/Standing (No. of years) .............................. Signature

VAEM

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