Annexure III

PROPOSAL FORM FOR LIC’s HEALTH PLUS POLICY – PLAN 901

• IN UNIT-LINKED POLICIES, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE

POLICYHOLDER.

• LIC’s Health Plus is a ULIP plan which is different from the traditional policies in the sense that it is subject
to market risks.

• LIC does not authorize its agents/intermediaries, staff and officials to express their opinion on the future
performance of the “ULIP” fund, excepting the prescribed illustrative rate of 6% and 10% growth.

Branch Office Division

………………………………………...FOR OFFICE USE ONLY……………….…………………

……………………

Inward No.:
Underwriter’s Decision Policy No. allotted

Date of receipt of proposal:

ALL ANSWERS ARE TO BE FILLED IN

BLOCK LETTERS. ANSWERS MUST BE
Agent’s Name & Code No.: GIVEN IN WORDS.
STROKES OF PEN OR DOTS WILL NOT BE
ACCEPTED AS REPLIES.

Amount Paid& Date of expiry:

Licence No. Cheque/DD No.

Dev. Officer’s Name & Code

Cash Drawn on (City/Town)

Name of the Bank

A. PERSONAL DETAILS

Full Name of the

proposer(Please
attach proof of
identity)

Fathers Full Name

Address for
Communication
(Please attach
proof of residence)

Pin code

Permanent
Address

Pin code

Nationality Qualification Present Occupation

Email id Income Source Employer’s Name

Tel. No. (Off) Annual Income Place of Service

Tel. No.(Res) ‘PAN’ Number Length of Service

Income Tax
Mobile Phone (Yes / No) Exact Nature of Duties
Assessee

B. NOMINEE DETAILS If Nominee is a minor, furnish the following:

Appointee’s Name
Full Name

Address
Age

Relationship Signature of
to the proposer Appointee

C. DETAILS OF ALL MEMBERS TO BE INSURED ( INCLUDING THE PRINCIPAL INSURED)

Insured Member’s Name Relationship Sex Age DOB Age Initial Daily Cash Benefit
to the proof
Proposer
Note Please check the product features for conditions regarding inclusion of family members.
Please submit a separate form (Annexure I) duly filled and signed by the member who is to be included as a
beneficiary.
If the member to be included is a minor, please submit a separate form (Annexure II) duly signed by the
proposer on behalf of the minor.

D. ADDITIONAL PARTICULARS FOR CONSIDERATION OF THE PROPOSAL

Plan Mode No. of lives to be covered Installment Premium Additional Premium

E. HEALTH DETAILS AND MEDICAL INFORMATION

Height cms Weight kgs

1. Do you smoke or consume any form of tobacco and /or alcohol? ≤ Yes  No

2. Are you currently taking any medication or drugs, either prescribed or not prescribed by a doctor, or have
you suffered from any illness, disorder, disability or injury during the past 5 years which has required any
≤ Yes  No
form of medical or specialized examination (including X-ray, gynaecological investigations, pap smear, or
blood tests), consultation, hospitalization or surgery?

2. Do you have any proposal for life, medical, health, accident, disability cover, critical illness or any other
health-related insurance that has been postponed, declined or accepted on special terms?
≤ Yes  No

2. Do you have a parent and /or a brother or a sister who has suffered/suffering from, or died under the age ≤ Yes  No
of 60 due to any of the following conditions: Heart disease, diabetes, stroke, hypertension, raised
cholesterol, cancer, or any hereditary disease?

2. Do you have any surgery planned or are you currently aware of any medical condition that might require
medical advice/surgery in the near future?
≤ Yes  No

6. Have you suffered/suffering from any of the following:

a) Hypertension or High blood pressure ≤ Yes  No

b) Diabetes ≤ Yes  No

c) Cardiovascular disease e.g.: Palpitations, heart attack, Stroke, chest pain ≤ Yes  No

d) Genitourinary disease e.g.: Kidney disorder, Bladder disorder, urine abnormality, renal stones or genital ≤ Yes  No
organ disorder.
 e) Cancer of any type e.g.: Leukaemia (blood cancer), cyst or growth of any kind ≤ Yes  No

f) Mental disorder e.g.: Depression, anxiety, schizophrenia or any other mental or nervous disorder. ≤ Yes  No

g) Endocrine diseases e.g.: Thyroid or any other hormonal disorder ≤ Yes  No

h) Digestive disease e.g.: Liver and gall bladder disorder, gastric ulcer, bleeding from intestine or any other
disorder of the digestive tract ≤ Yes  No

i) Respiratory diseases e.g.: Asthma, pneumonia, bronchitis, tuberculosis, persistent cough, or any other
disorder of the chest or lungs. ≤ Yes  No

j) Musculoskeletal diseases e.g.: prolapsed disc, back or neck complaint, any physical disability or other
disorder of the bones, joints, arthritis, gout etc ≤ Yes  No

k) Neurological diseases e.g.: Fits, epilepsy, recurrent headache, paralysis, any other disease or disorder of
the brain, spinal cord or nerves.
≤ Yes  No

l) Congenital disorders ≤ Yes  No

m) Anaemia, hemophilia, thalassemia or any other disorders of the blood ≤ Yes  No

7. Have you ever been tested positive for HIV / AIDS, hepatitis B or C or sexually
transmitted diseases? ≤ Yes  No

7. Have you been absent from work for more than 5 continuous days in the last two
years due to health reasons?
≤ Yes  No

7. Have you ever been involved or planning to be involved in a dangerous sport or

hobby? e.g.: diving, mountaineering, parachuting, private aviation, racing, etc.
≤ Yes  No

7. Are you currently covered under any health insurance policy with LIC or any other company? ≤ Yes  No

11. Whether any Proposal submitted and is pending in any of the LIC Offices ? ≤ Yes  No

If the answer to any of the above questions (from 1-9) is “yes” please give details (such as units consumed,
diagnosis and further information as cured, still under treatment, treatment from / to, copies of hospital/
diagnostic reports, reasons, details of declined/rejected/cancelled proposals etc) hereunder. Please attach
separate sheet if necessary. For question numbers 10 & 11, if the answer is “ yes “, please submit details in a
separate sheet.
F. ADDITIONAL QUESTIONNAIRE FOR FEMALE LIVES

Are you pregnant now? Date of last Delivery Have you ever had any abortion or mis- Date of last
carriage or caesarian section? If so give Menstruation
details in a separate sheet.

Husband’s Full Name His Occupation His Annual Income

G. ADDITIONAL QUESTIONS IN THE CASE OF SERVICES IN ARMED FORCES

Wing to which Rank therein Date of last Medical Medical category after Were you ever below A-1 category If so
Examination
you belong Medical Examination when
 H. INVESTMENT PATTERN OF THE FUND

FUND TYPE Investments in Short-term investments such as Investment in listed Details and objective of
Govt./Govt. Guaranteed Money Market instruments (incl. equity shares the fund for risk/return
securities/ corporate debt govt. securities and corporate
debt)

Health Plus Not less than 50% Not more than 90% Not less than 10% & Income and Growth –
Fund Not more than 50% Low Risk

I. ADDITIONAL QUESTIONS TO BE ANSWERED BY THE PROPOSER

a. Whether the terms and conditions of the proposed plan have been explained to you by the agent ≤ Yes  No

b. Have you understood fully, the terms and conditions of the plan you propose to take ≤ Yes  No

DECLARATION BY PROPOSER

I _______________________, hereby declare that I have read the proposal form fully and the same was
interpreted to me by the agent and also declare that I have understood the nature of the questions and the
importance of disclosing all material information while answering such questions. I hereby declare that the
foregoing statements and answers to all questions, including those in the annexures signed by me, 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 and
that if any untrue averment be contained therein, the said contract shall be absolutely null and void and all
monies which shall have been paid in respect thereof shall stand forfeited to the Corporation. 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 agree that such authority
having such knowledge or information shall at anytime be at liberty to divulge any such knowledge or information
to the Corporation and its representatives (including but not limited to Third Party Administrators).

And I further agree that, if after the date of submission of the proposal but before the issue of the first
Premium Receipt (i) any change in the state of my health or my occupation or any adverse circumstances
connected with my financial position or (ii) if a proposal for an assurance or application for revival of policy on my
life made to any office of the Corporation or with any other insurer is withdrawn or dropped, deferred or accepted
at increased premium or subject to a lien or on terms other than as proposed, I shall forthwith intimate the same
to the Corporation in writing to reconsider the terms of acceptance of assurance. Any omission on my part to do
so shall render this Assurance invalid and all moneys, which shall have been paid in respect thereof, shall stand
forfeited to the Corporation. I hereby give my consent for undergoing medical examination/tests including test for
HIV as required by Corporation. I further declare that I have discussed my financial standing with the agent/
intermediary. I confirm that I have been informed about and have understood the benefits and exclusions under
this product for which I have made this application. In consultation with the agent/ intermediary, I have taken a
personal and independent decision in an informed manner to go for the Plan. I understand that the “application
money” deposited by me as a token consideration under this proposal for insurance, and the closing NAV on the
date of completion of this proposal only will be applied for allotment of units.

Dated at---------------------------------------on the ----------------------------day of---------------------200

Signature of witness __________________ Signature or

Name and address ____________________ Thumb Impression
____________________ of the proposer : _______________________

In case form is filled up / signed in a language different from that of the Proposal Form:
Declaration by the person filling in the form: “I hereby declare that I have fully explained the above
questions to the proposer in _________ language and I have truthfully recorded the answers given by the
proposer.”

Name &Address ______________________ Signature :_________________________

of the Declarant: _____________________ of the Declarant
Declaration by the Proposer:

“I certify that the contents of the form and documents have been fully explained to me by Mr/
Ms:___________________ and I have understood the significance of the proposed contract”.

Signature or Thumb impression of the

Proposer:___________________________

In case the Proposer is illiterate, the thumb impressions of the Proposer should be attested by a
person of
standing whose identity can easily be established, but unconnected with the Corporation and this
declaration
should be made by him/her.

“I hereby declare that I have fully explained the above questions and contents of the proposal form to the
proposer in ______________language, and that the proposer has affixed his / her thumb impression above, in
my presence, after fully understanding the contents thereof.”

Name & Address ____________________ Signature of the :____________________

of the Declarant: _____________________ attester and Declarant

FOR MEDICAL CASES ONLY

I certify that the proposer has signed / put his / her thumb impression in my presence after admitting that all
answers to questions under “Section E “ in this proposal form are properly recorded.

----------------------------------------------------- --------------------------------------
Signature or Thumb Impression of the Proposer Signature of the Medical Examiner
 RELEVANT PROVISIONS UNDER INSURANCE ACT 1938

SECTION 41 – PROHIBITION OF REBATES

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 Insurance in respect of
any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on
the policy, nor shall any person taking out or renewing or continuing a policy, accept any rebate, except such rebate as may be allowed in accordance with
the published prospectus or tables of the insurer. Provided that acceptance by an insurance agent of commission in connection with a policy of life
insurance taken out by himself on his own life shall not be deemed to be an acceptance of a rebate of premium within the meaning of this sub section if at
the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the
insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.
SECTION 45 – INDISPUTABILITY CLAUSE

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 any report of a medical officer or referee or friend of the Insurer or in any other document leading
to the issue of the Policy, was inaccurate or false, unless the insurer shows such statement was on material matter or suppressed facts which it was
material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that the 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.

Check List
Please verify the following items under this checklist before submitting the proposal form to
LIC office.

S. Title Please Tick 

No Yes or No

1 Photo Addendum sheet (Form No. HI/PPL/1/a) with photos of members to be covered under
Health Insurance Policy (Photos to be pasted as per instructions on the addendum)
♦ YES ♦ NO

2 Bank details addendum sheet (Form No. HI/PPL/1/b)

♦ YES ♦ NO

3 Cancelled cheque of the policyholder (to be pasted on the addendum sheet)

♦ YES ♦ NO

4 Addition form (Annexure I & II )

♦ YES ♦ NO

5 Standard Age Proof of the proposer (Date of Birth Certificate)

♦ YES ♦ NO

6 Standard Age Proof of the Members separately for each member

♦ YES ♦ NO

7 Full details of the health policies held on the life of the proposer in a separate sheet (if the
space provided in the proposal is not sufficient)
♦ YES ♦ NO
 8 Full details of the Health and medical information on the lives of the proposer and members
on a separate sheet (if the space provided is not sufficient)
♦ YES ♦ NO

9 Medical reports / Special reports of the proposer and members separately

♦ YES ♦ NO

10 Consideration amount towards First premium

♦ YES ♦ NO

11 Proof of Residence (Telephone bill, Ration Card, Electricity bill, Bank A/c Statement, Letter
from any recognized public authority)
♦ YES ♦ NO

12 Proof of identity (Pass port, ‘PAN’ Card, Driving License, Voter’s identity, letter from a
recognized public authority verifying the identity and residence proof of the proposer)

13 Income Proof (Standard) (Any of the following)

IT Assessment orders /IT Returns,
Employer’s Certificate, ♦ YES ♦ NO
Audited Company Accounts
Audited Firm accounts ♦ YES ♦ NO
Partnership deed
Income Proof (Non Standard) (Any of the following)
♦ YES ♦ NO
Chartered Accountant’s Certificate ♦ YES ♦ NO
Agricultural Income Certificate
Agricultural land details & Income assessments ♦ YES ♦ NO
Bank Cash flow statements and pass book
(The list is only illustrative and not exhaustive)
♦ YES ♦ NO
♦ YES ♦ NO
♦ YES ♦ NO
♦ YES ♦ NO

14 Whether declarations have been signed at all places and duly witnessed
♦ YES ♦ NO

15 Whether Details and signature of appointee are taken in case of nominee being minor
♦ YES ♦ NO

16 Whether all fields are properly filled in (without any blanks or dashes)
♦ YES ♦ NO

17 Whether corrections in the proposal form are authenticated by the proposer

♦ YES ♦ NO

Medical Requirements

Major Surgical Benefit Age Nearest Birthday (yrs)

Sum Assured
Up to 35 36 – 40 41 – 50 51 - 55

50,000 to 1,00,000 NM NM NM A

1,00,001 to 2,00,000 NM NM A B
2,00,001 to 3,00,000 NM A A B

3,00,001 to 5,00,000 A B B C

Where A – MER, FBS, RUA; B – MER, FBS, RUA, HbA1c, ECG ; C – MER, FBS, RUA, HbA1c, TMT
Note: The above requirements are mandatory. In addition, if any other Medical/ Special reports are
called for by the underwriter, they will have to be furnished.
 (Form No. HI/ACR/1)
HI/ACR/1
HI/ACR/1

AGENT’S CONFIDENTIAL REPORT/MORAL HAZARD REPORT

Agent’s Name Club License No. Date of expiry Branch Code

Membership

Agent’s Code D.O. Code

Name of Life Proposed Age Occupation

Nature of duties

1. (a) Acquaintance with the proposer (No. of Years):

(b) Relationship with the proposer :

(c) Educational qualification of the Proposer:

2. (i) Income of the proposer from : Amount per annum Remarks

(a) Employment

(b) Business / Profession

(c ) HUF

(d) Agricultural Income

(e) Income from other sources

Total
(ii) Proof of income verified in respect of income stated above

(a) Salary sheet or certificate issued by the Employer :

(b) Certificate issued by the C.A.(copies of IT returns enclosed) :

(c) PAN / GIR No. of the proposer :

3. Physical Measurements and Identification Marks of the Proposer and other Members (beneficiaries) to be insured under
the proposal.

QQQ Name QQQQ Height Weight Abdomen Chest(Cms) Identification Marks

( Cms) ( kgs) ( Cms)
Exp Insp.

1
PROPOSER
2

1
MEMBER 1
2

1
MEMBER 2
2

1
MEMBER 3
2

1
MEMBER 4
2

Page 1 of 2 of ACR
 Page 2 of 2 of ACR

4. Declaration by the Agent

I hereby declare that I have discussed the following aspects with the proposer/ members covered and the
statements recorded by me reflect the true answers and correct statements and bear testimony to the replies
given by the proposer/members covered:
I. I am personally satisfied that, the proposer is financially sound and that his income justifies the
current proposal.

II. I have personally seen the proposer/members covered and satisfied that he/ she does not have any
physical deformity or impaired sight or hearing problem or any mental retardation.

III. My inquiries regarding the health condition of the proposer/members covered do not reveal that the
proposer/members covered has suffered from any illness or has been investigated or hospitalized or
has undergone any surgical procedure or operation.

IV. I confirm that general state of health of proposer/members covered is good.

V. I have discussed with the proposer/members covered about the status of all his / their previous
health policies and that no policy has lapsed during the last 5 years and all his / their policies are in
force.

VI. I have discussed and I am aware that no proposal or revival of policy on the life of the
proposer/members covered has been deferred, declined or dropped or accepted at terms other than
those proposed.

VII. I have also personally discussed about the occupation, financial and social status of the
proposer/members covered and I am aware that neither these nor any other circumstances will add
to the risk.

VIII. I have fully explained the terms and conditions of the health insurance plan to the proposer /
beneficiary.

I further declare that the foregoing statements are true and correct to the best of my knowledge.

Dated at on the day of 200

Agent’s Name and address ___________________ Signature of the Agent

___________________
Phone Number ___________________
(To be completed by Dev. Officer) (To be completed by ABM(s)/ B. M / Sr.B.M/Chief Mgr.)

I am satisfied with the identity of the proposer/ members I am satisfied with the identity of the proposer/ members covered
covered and on the basis of my independent enquiries, I and on the basis of my independent enquiries, I hereby declare that
hereby declare that the foregoing statements are true and the foregoing statements are true and correct to the best of my
correct to the best of my knowledge and belief knowledge and belief

Dated at on the day of 200 #### Dated at on the day of 200 200

Signature Signature

Name Name

Designation Designation

HI/PPL/1/a

Life Insurance Corporation of India

Health Plus Plan Proposal Form – Photo Addendum
for preparation of Identity Cards
 Name of the Proposer

Proposer Spouse/ Member 2 Member 3 Member 4

Member 1

Affix Stamp size Affix Stamp size Affix Stamp size Affix Stamp size Affix Stamp size
photo only photo only photo only photo only photo only

Name

DOB

Gender

Relation to
proposer

Signature of the
Proposer
 - - - -- - - -- - - -- - -- - - - - - - - - - - - - - - - -- - -- - --- - - - - - - - - - -- - -- -- - -- - - - -- - - - -

To be filled in by Divisional Office Health Unit

Policy Number Division Name & Code Branch Name & Code Sent to TPA on

Prepared By Checked by Manager (Health Insurance)

IMPORTANT: Form to be detached and sent to the TPA for the issue of Health Card

Life Insurance Corporation of India

Health Plus Plan Proposal Form – Addendum for Bank Details
QQ

HI/PPL
/1/b

Name of the Proposer

Bank Name
Bank
Details of
Proposer

Bank Branch location & Code

Bank Account Number

NEFT / RTGS
IFSC- CODE NUMBER

MICR No

Note: I undertake to intimate regarding change in bank details to LIC promptly and I am aware that
claims arising under this Policy will be settled through the above Bank Account only.

Signature of the Proposer

 Affix a cancelled cheque / Xerox copy of cheque here

To be filled by Divisional Health Unit

The payments will be made based on the accuracy of the above data. Divisional Health Unit is
requested to verify data in Policy master and ensure accuracy of data.
 Policy Number Division Name & Code Branch Name & Code

The Bank Account Details are verified with the data captured in the Policy Master and are
found to be in order and where discrepancies have been noticed the data has been corrected.

Prepared by Checked by Manager (Health Insurance)

LIC’s HEALTH PLUS POLICY – PLAN 901 AnnexureI to Proposal Form

Form to be filled in by the Member (Beneficiary) in case the member is not a

Minor

Member’s Name Division Code

Date of Birth Sex Branch Code

Relationship to If spouse, Proposal Number

Policyholder date of
marriage

Occupation Agents Code

Employer’s DO Code
name
 Nature of duties Initial Daily Cash
Benefit opted

Details of the Principal Insured (Policy Holder)

Name

Policy Number

HEALTH DETAILS AND MEDICAL INFORMATION

Height cms Weight kgs

1. Do you smoke or consume any form of tobacco and /or alcohol? ≤ Yes  No

2. Are you currently taking any medication or drugs, either prescribed or not prescribed
by a doctor, or have you suffered from any illness, disorder, disability or injury during the past 5 years
which has required any form of medical or specialized examination (including X-ray, gynaecological
investigations, pap smear or blood tests), consultation, hospitalization or surgery? ≤ Yes  No

3. Do you have any proposal for life, medical, health, accident, disability cover, critical illness or any other
health-related insurance that has been postponed, declined or accepted on special terms?
≤ Yes  No

4. Do you have a parent and /or a brother or a sister who has suffered/suffering from, or died under the
age of 60 due to any of the following conditions: Heart disease, diabetes, stroke, hypertension, raised
≤ Yes  No
cholesterol, cancer, or any hereditary disease?

5. Do you have any surgery planned or are you currently aware of any medical condition that might
require medical advice/surgery in the near future?
≤ Yes  No

6. Have you suffered/suffering from any of the following:

a) Hypertension or High blood pressure ≤ Yes  No

b) Diabetes ≤ Yes  No

c) Cardiovascular disease e.g.: Palpitations, heart attack, Stroke, chest pain ≤ Yes  No

d) Genitourinary disease e.g.: Kidney disorder, Bladder disorder, urine abnormality,

renal stones or genital organ disorder.
≤ Yes  No

e) Cancer of any type e.g.: Leukaemia (blood cancer), cyst or growth of any kind ≤ Yes  No

f) Mental disorder e.g.: Depression, anxiety, schizophrenia or any other mental or

nervous disorder.
≤ Yes  No
 g) Endocrine diseases e.g.: Thyroid or any other hormonal disorder ≤ Yes  No

h) Digestive disease e.g.: Liver and gall bladder disorder, gastric ulcer, bleeding from
intestine or any other disorder of the digestive tract
≤ Yes  No

i) Respiratory diseases e.g.: Asthma, pneumonia, bronchitis, tuberculosis, persistent

cough, or any other disorder of the chest or lungs.
≤ Yes  No

j) Musculoskeletal diseases e.g.: prolapsed disc, back or neck complaint, any physical
disability or other disorder of the bones, joints, arthritis, gout etc
≤ Yes  No

k) Neurological diseases e.g.: Fits, epilepsy, recurrent headache, paralysis, any other
disease or disorder of the brain, spinal cord or nerves.
≤ Yes  No

l) Congenital disorders ≤ Yes  No

m) Anaemia, hemophilia, thalassemia or any other disorders of the blood ≤ Yes  No

7. Have you ever been tested positive for HIV / AIDS, hepatitis B or C or sexually
transmitted diseases?
≤ Yes  No

8. Have you been absent from work for more than 5 continuous days in the last two
years due to health reasons?
≤ Yes  No

9. Have you ever been involved or planning to be involved in a dangerous sport or

hobby? e.g.: diving, mountaineering, parachuting, private aviation, racing, etc.
≤ Yes  No

10. Do you currently have any health insurance policy with LIC or any of the other companies? ≤ Yes  No

11. Whether any Proposal submitted and is pending in any of the LIC Offices? ≤ Yes  No

If the answer to any of the above questions (from 1-9) is “yes” please give details (such as units consumed,
diagnosis and further information as cured, still under treatment, treatment from / to, copies of hospital/
diagnostic reports, reasons, details of declined/rejected/cancelled proposals etc) hereunder. Please attach
separate sheet if necessary. For question numbers 10 & 11, if the answer is “ yes “, please submit details in a
separate sheet.

IMPORTANT: THE FOLLOWING DOCUMENTS NEED TO BE ATTACHED TO THIS FORM

1. Age proof to be attached
2. Photo addendum Form to be submitted in case of ‘Additions of new member to existing Policies’

ADDITIONAL QUESTIONNAIRE FOR FEMALE LIVES

Are you pregnant now? Date of last Delivery Have you ever had any abortion or mis-carriage or Date of last
 caesarian section? If so give details in a separate Menstruation
sheet.

Husband’s Full Name His Occupation His Annual

Income

ADDITIONAL QUESTIONS IN THE CASE OF SERVICES IN ARMED FORCES

Wing to which Rank therein Date of last Medical Medical category after Were you ever below A-1 category If so
you belong Examination Medical Examination when

ADDITIONAL QUESTIONS TO BE ANSWERED BY THE PROPOSER

a. Whether the terms and conditions of the proposed plan have been explained to you by the agent ≤ Yes  No

b. Have you understood fully, the terms and conditions of the plan you propose to take ≤ Yes  No

DECLARATION BY THE BENEFICIARY

I ____________________________________hereby declare that the foregoing statements and

answers to all questions in this annexure signed by me, 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 and that if any untrue averment
be contained therein, the said contract shall be absolutely null and void and all monies which shall have been
paid in respect thereof shall stand forfeited to the Corporation. 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 agree that such authority having
such knowledge or information shall at anytime be at liberty to divulge any such knowledge or information to
the Corporation and its representatives (including but not limited to Third Party Administrators).

And I further agree that, if after the date of submission of the proposal but before the issue of the first Premium
Receipt (i) any change in the state of my health or my occupation or any adverse circumstances connected
with my financial position or (ii) if a proposal for an assurance or application for revival of policy on my life
made to any office of the Corporation or with any other insurer is withdrawn or dropped, deferred or accepted
at increased premium or subject to a lien or on terms other than as proposed, I shall forthwith intimate the
same to the Corporation in writing to reconsider the terms of acceptance of assurance. Any omission on my
part to do so shall render this Assurance invalid and all moneys, which shall have been paid in respect
thereof, shall stand forfeited to the Corporation. I hereby give my consent for undergoing medical
examination/tests including test for HIV as required by Corporation. I confirm that I have been informed
about and have understood the benefits and exclusions under this product for which I have made this
application. In consultation with the agent/ intermediary, I have taken a personal and independent decision in
an informed manner to go for the Plan.
Dated at---------------------------------------on the ----------------------------day of---------------------200

Signature or Thumb Impression of the Beneficiary

C Consent by the Principal Insured -- I hereby give consent for including the above proposer
as a member beneficiary in my policy no.______________

Signature of the Principal Insured

In case form is filled up / signed in a language different from that of the Proposal Form:
Declaration by the person filling in the form:
“I hereby declare that I have fully explained the above questions to the above beneficiary in _________
language and I have truthfully recorded the answers given by the above beneficiary.”

Name & Address ___________________ Signature :____________________

of the Declarant: ___________________ of the Declarant
___________________

Declaration by the Beneficiary

“I certify that the contents of the form and documents have been fully explained to me by Mr /
Ms:__________________________________ and I have understood the significance of the proposed contract.

Signature or thumb impression of the Beneficiary:___________________________

In case the Beneficiary is illiterate, the thumb impressions of the Beneficiary should be attested by a
person of standing whose identity can easily be established, but unconnected with the Corporation
and this declaration should be made by him/her.

“I hereby declare that I have fully explained the above questions and contents of the Annexure I to the
beneficiary in ______________language, and that the beneficiary has affixed his / her thumb impression above
in my presence after fully understanding the contents thereof.”

Name & Address ______________________ Signature of the attester :____________________

of the Declarant: ______________________ and Declarant
______________________

FOR MEDICAL CASES ONLY

I certify that the beneficiary has signed / put his / her thumb impression in my presence after admitting that, all
answers to questions in this Annexure I are properly recorded.

--------------------------------- --------------------------------------
Signature or Thumb Impression of the Beneficiary Signature of the Medical Examiner

IMPORTANT: THE FOLLOWING DOCUMENTS NEED TO BE ATTACHED TO THIS FORM

1. Age proof to be attached
2. Photo addendum Form to be submitted in case of ‘Additions of new member to existing Policies’

LIC’s HEALTH PLUS POLICY – PLAN 901 AnnexureII to Proposal Form

Form to be filled by the proposer in case the Beneficiary is a Minor.

Member’s Name Division Code

Date of Birth Sex Branch Code

Relationship to If adopted, date Proposal Number
Policyholder of adoption

Occupation Agents Code

Name of the DO Code

school / college

Std / Class Initial Daily Cash

Benefit opted

Details of the Principal Insured (Policy Holder)

Name

Policy Number

HEALTH DETAILS AND MEDICAL INFORMATION

Height cms Weight kgs

1. Is the life to be assured currently taking any medication or drugs, either prescribed or not
prescribed by a doctor, or has the minor ever suffered from any illness, disorder, disability or
injury during the past 5 years which has required any form of medical or specialised ≤ Yes  No
examination (including X-ray, blood tests etc), consultation, hospitalisation or surgery?

2. Has the life to be assured any surgery planned or has the life to be assured currently been
advised to seek medical advice/surgery in the near future? ≤ Yes  No

3. Has the life to be assured suffered/suffering from any of the following:

a) Cardiovascular disease e.g.: congenital heart disease, Palpitations, heart attack,

Stroke, chest pain etc ≤ Yes  No

b) Diabetes ≤ Yes  No

c) Hypertension or High blood pressure ≤ Yes  No

d) Genitourinary disease e.g.: Kidney disorder, Bladder disorder, urine abnormality, renal
stones or genital organ disorder. ≤ Yes  No

e) Cancer of any type e.g.: Leukaemia (blood cancer), cyst or growth of any kind ≤ Yes  No

f) Mental disorder e.g.: Depression, anxiety, schizophrenia or any other mental or

nervous disorder. ≤ Yes  No

g) Endocrine diseases e.g.: Thyroid or any other hormonal disorder ≤ Yes  No

 h) Digestive disease e.g.: Liver and gall bladder disorder, gastric ulcer, bleeding from
intestine or any other disorder of the digestive tract ≤ Yes  No

i) Respiratory diseases e.g.: Asthma, pneumonia, bronchitis, tuberculosis, persistent

cough, or any other disorder of the chest or lungs. ≤ Yes  No

j) Musculoskeletal diseases e.g.: prolapsed disc, back or neck complaint, any physical
disability or other disorder of the bones, joints, arthritis, gout etc ≤ Yes  No

k) Neurological diseases e.g.: Fits, epilepsy, recurrent headache, paralysis, any other
disease or disorder of the brain, spinal cord or nerves.
≤ Yes  No

l) Congenital disorders. ≤ Yes  No

m) Anaemia, hemophilia, thalassemia or any other disorders of the blood ≤ Yes  No

4. Has the life to be assured ever been tested positive for HIV / AIDS, hepatitis B or C? ≤ Yes  No

5. Has the life to be assured been absent from school/college for more
than 5 continuous days in the last two years due to health reasons? ≤ Yes  No

6. Has the life to be assured involved or planning to be involved in a dangerous sport or hobby? e.g.:
diving, mountaineering, parachuting, private aviation, racing, etc. ≤ Yes  No

7. Does the life to be assured have any health insurance policy with the LIC or
any of the other companies? ≤ Yes  No

8. Whether any Proposal submitted and is pending on the life to be assured in any of the LIC Offices ? ≤ Yes  No

If the answer to any of the above questions (from 1-6) is “yes” please give details (such as units consumed,
diagnosis and further information as cured, still under treatment, treatment from / to, copies of hospital/
diagnostic reports, reasons, details of declined/rejected/cancelled proposals etc) hereunder. Please attach
separate sheet if necessary. For question numbers 7 & 8, if the answer is “ yes “, please submit details in a
separate sheet.

IMPORTANT: THE FOLLOWING DOCUMENTS NEED TO BE ATTACHED TO THIS FORM

1. Age proof to be attached
2. Photo addendum Form to be submitted in case of ‘Additions of new member to existing Policies’
 DECLARATION BY PROPOSER

I_________________________________________ hereby declare that the foregoing statements and answers to all
questions in this annexure signed by me, 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 for inclusion of the minor life mentioned above as one of the
beneficiaries under this contract and that if any untrue averment be contained therein, the said contract shall be
absolutely null and void and all monies which shall have been paid in respect thereof shall stand forfeited to the
Corporation. 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 the minor
life mentioned in this Annexure II, concerning his/her health 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 agree that such authority having such knowledge or information shall at anytime be
at liberty to divulge any such knowledge or information to the Corporation and its representatives (including but
not limited to Third Party Administrators).

And I further agree that, if after the date of submission of the proposal but before the issue of the first Premium
Receipt (i) any change in the state of health of the minor life mentioned in this Annexure or (ii) if a proposal for
an assurance or application for revival of policy on the minor life, mentioned in this Annexure, made to any office
of the Corporation or with any other insurer is withdrawn or dropped, deferred or accepted at increased premium
or subject to a lien or on terms other than as proposed, I shall forthwith intimate the same to the Corporation in
writing to reconsider the terms of acceptance of assurance. Any omission on my part to do so shall render this
Assurance invalid and all moneys, which shall have been paid in respect thereof, shall stand forfeited to the
Corporation. I hereby give my consent for letting the beneficiary mentioned in this Annexure II to undergo
medical examination/tests including test for HIV as required by Corporation.

Dated at---------------------------------------on the ----------------------------day of---------------------200

Signature of witness: Signature or Thumb Impression of the proposer (PI)

Name and address : ______________________
______________________

In case form is filled up / signed in a language different from that of the Proposal Form:

Declaration by the person filling in the form:

“I hereby declare that I have fully explained the above questions to the proposer in _________ language and I
have truthfully recorded the answers given by the proposer .”

Name & address __________________ Signature :____________________

of the Declarant: __________________ of the Declarant
__________________
__________________

Declaration by the Proposer:

“I certify that the contents of the form and documents have been fully explained to me by Mr /
Ms:__________________________________ and I have understood the significance of the proposed contract”.

Signature or thumb impression of the Proposer:___________________________

In case the Proposer is illiterate, the thumb impressions of the Proposer should be attested by a
person of standing whose identity can easily be established, but unconnected with the Corporation
and this declaration should be made by him/her.

“I hereby declare that I have fully explained the above questions and contents of the Annexure II to the proposer
in ______________language, and that the proposer has affixed his / her thumb impression above in my
presence after fully understanding the contents thereof.”

Name & Address ________________________ Signature of the attester :____________________

of the Declarant: ________________________ and Declarant
________________________

FOR MEDICAL CASES ONLY

I certify that the proposer has signed / put his / her thumb impression in my presence after admitting that all
answers to questions in this Annexure II are properly recorded.

---------------------------------------------------- --------------------------------------
Signature or Thumb Impression of the Proposer Signature of the Medical Examiner

IMPORTANT: THE FOLLOWING DOCUMENTS NEED TO BE ATTACHED TO THIS FORM

1. Age proof to be attached
2. Photo addendum Form to be submitted in case of ‘Additions of new member to existing Policies’