Life Insurance Corporation of India IPR-F300-V1.

0
IPR-F300-RE-V12.0
FORM NO. 300 (Rev. 98 )
PROPOSAL FOR INSURANCE ON OWN
LIFE
Recent (Not to be used on the lives of Minors)
Passport Inward Number: Date.
Size Photo

(Established by the Life Insurance Corporation Act, 1956)

Reset Form 000012 20/04/2017
To be filled in by Agent: Division Code: 086 Branch Office Code: 870 FOR OFFICE USE ONLY :
Agents Name: SANDIP Satl Branch Code: 086
(Keep blank if not required) Proposal no :
Agents Code : 01340870 Dev. Officer Code: Amt of Deposit :
0019022 B.O.C No.
Ag .License No. Date of Expiry : Date : Rural/Urban
Proposal. Dt : 20/04/2017 Medical Code : General Urban
(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. )
Title: SRI Surname: SHETH Initial: P H Object of Insurance :
First Name Middle Name Last Name
Key Man Insurance
Full name (Surname first) and
PRERIT address to which communication
HIMANSHU SHETH are to be sent.
Name for Address Place of Birth :
Addr1:
-> PRERIT HIMANSHU SHETH
Address
Addr2: 1 E - 401. GREEN ENCLAVE APPT,
address BESIDE SARDAR BRIDGE, Nationality : Sex :
Addr3: 3
Address ADAJAN, SURAT.
INDIAN MALE
Pin: 395009 Mobile No. (10 digits) 8016983573
Tel Nos (with:STD Code):Res: Off:
2A Residential address, if different from above : Click to Copy ... Nature of Age-Proof submitted:
Addr1:
Baptism
Addr2:
Age (nearer Date of Birth
Addr3: birthday)
Pin: 000000 Yrs. 30/11/1983

e-mail:
Short Name : Fathers Full name (Surname First )
P H SHETH
2B. Nominees Full name(Surname first) and address Copy ... Age Relationship to Title Code
Name : UNNATI P SHETH yourself

Addr1: 30 Wife
Addr2:
Addr3: Yrs.
Pin :

If Nominee is a minor, appointees full name and address Age Relationship to Signature of
Name : nominee Appointee as
token of consent
Addr1:
Addr2:
Addr3:
Yrs.
Pin :

Note: It is in the interest of the Proposer to avail the facility of nomination

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 Life Insurance Corporation of India IPR-F300-V1.0
IPR-F300-RE-V12.0
3
Plan Policy Prem- Sum Proposed Term rider sum Is accident Benefit Date of Total Amount
Term proposed (if required) required? Commencement. If
ium (Rs.) policy is to be dated
Deposited
Term YES back indicate that (Rs. )
Critical illness sum date .
proposed (if Sum Assured For
required ) Rs. the A B(Rs.)

823 27 27
Boc1- No. Boc1-Date Boc2-No Boc2-Date

Mode(Yly, Half- Paying Authority Code Deptt. No. Badge or S.R. No.
Yly,Qtrly,Mly, SSS
,Single )
PA: Sub PA:
Ordinary Yearly

4A. Present Occupation Exact nature of duties

Self Employed with Tax SERVICE

4B. Name of Present Employer Length of Service with him (years)

SERVICE 10
5 Educational Qualification Annual Income Source of Are you an Income Tax
(Rs . ) Income Assessee ?

Graduate/Post Graduate 100000 SER NO

6. If you are employed in the Armed forces, please state Self No

Wing to which you Rank therein Date of last Medical Medical Category after Were you ever
belong Examination Medical Examination below A-1
(dd/mm/yyyy) category ? if so
when ?

7. Is your life now being proposed for another assurance or an YES/NO DETAILS
application for revival of a policy on your life or any other
proposal under consideration in any office of the corporation or
NO
to any other insurer? If yes give details .
8A. Has a proposal( or an application for Answer If yes give details
revival of a policy) on your life made to YES or
any office of the corporation or to any NO NO
other insurer ever been :
Withdrawn , Deferred , Dropped or
Declined ?
Accepted with extra Premium or Lien ?

Accepted on terms otherwise than those

proposed ?
8B. Have you during past one year
returned any policy of the corporation as
the same was not acceptable to you ? If
so give details :

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 Life Insurance Corporation of India IPR-F300-V1.0
IPR-F300-RE-V12.0
9.

Please give details of your previous insurance : ( including policies surrendered/lapsed during last 3 years)

Policy Insurance Table Sum Term Critical Amount Year Whether Med Whether If not
Companies Assurance accepted ical in force give
number from where
& Assured Illness Of Of as Or due
previous Term On Rider Rider Accident Issue proposed Non
for full date of
policy/policies Main Sum Sum Benefit at ordinary medi Sum last
have been Plan Assured Assured Taken rate, if not cal Assured premium
purchased with give paid or
address ( if details date
previous policy of
are from LIC of surrender
India, give
name of
Branch/DO)
at OR
In Force

at OR
In Force

at OR
In Force

at OR
In Force

at OR
In Force

at OR
In Force

at OR
In Force

at OR
In Force

at OR
In Force

at OR
In Force

N.B. : Corporation does not entertain any fresh proposal for insurance where a policy issued by the corporation has lapsed or
has been converted into paid up policy within the last 3 years.
10. Family History . Living Dead
SL Family Member Living Age State of Health Age Cause of death
/ Dead ( Living ) (Dead)
1
2
3
4
5
6
7
8
9
10

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 ..... Life Insurance Corporation of India IPR-F300-V1.0
IPR-F300-RE-V12.0
11.
Personal History Answer If yes, Please give full details
Yes or
No
(a) During the last five years did you
consult a Medical Practitioner for any
ailment requiring treatment for more
than a week ?
(b) Have you ever been admitted to any
hospital or nursing home for general
check up, observation, treatment or
operation ?
(c) Have you remained absent from
place of work on grounds of health
during the last 5 years ?
(d) Are you suffering from or have you
ever suffered from ailments pertaining
to liver, stomach, Heart, Lungs ,
Kidney, Brain or Nervous System ?
(e) Are you suffering from or have ever
suffered from Diabetes, Tuberculosis,
High Blood Pressure, Low Blood
Pressure, Cancer, Epilepsy, Hernia,
Hydrocele, Leprosy or any other
disease ?
(f) Did you ever have any bodily defect
or deformity ?
(g) Did you ever have any accident or
injury ?
(h) Do you use or have you ever used -
Alcoholic drinks
Narcotics
Any other drugs
Tobacco in any form
(i) What has been your usual state of
heath?
(j) Have you ever required or at present
availing/undergoing medical advice,
treatment or tests in connection with
hepatitis B or AIDS related condition.
12. In non-medical cases , please state Height ( Cms ) Weight ( Kg )
exact height in Cms. And weight in Kgs
( Without shoes )
FOR FEMALE PROPONENT
13A Are you Date of last delivery Have you had any abortion or miscarriage or Date of last Menstruation
pregnant now? (dd/mm/yyyy) Caesarian section ? if so give details (dd/mm/yyyy)

13B. Husbands full name

His Occupation

His annual Income

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 Life Insurance Corporation of India IPR-F300-V1.0
IPR-F300-RE-V12.0
13C.
Details of husbands Insurance :
Policy No. Insurance Companies Sum Assured Table & Term Present Status of the
from where the Policy
previous
policy/policies have
been purchased with
address(if previous
policies are from LIC
India, give name of
Branch/D.O)

14. Have you understood fully the terms & conditions of the
plan you propose to take ? Yes
DECLARATION BY THE PROPOSER
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 and that if any untrue averment be contained therein the said contract shall be absolutely
null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the 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 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.
And I further agree that if after the date of submission of the proposal but before the issue of first Premium Receipt (i) any
change in my occupation or any adverse circumstances connected with my financial position or the general health of myself or
that of any members of my family occurs or (ii) if a proposal for assurance or any application for revival of a policy on my life
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 . 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.

Dated at on the day of 20

Signature of witness Signature or Thumb Impression of the Person whose life

Name Is Proposed to be assured .
Occupation
Address

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 Life Insurance Corporation of India IPR-F300-RE-V12.0
IPR-F300-V1.0
1) Declaration by the person filing 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 .

Declarants Name and Address .

Signature.
I certify that the contents of the form and documents have been fully explained to me by ( Name , Designation, Occupation
Mr / Mrs and I have understood the significance of the proposed contract.

------------------------------------
Signature or thumb impression of the person
Whose life is proposed to be assured.

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 this form to the proposer in .
language and that the proposer has affixed the thumb impression above after fully understanding the contents thereof .

Name and 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 bonafied 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.

FOR MEDICAL CASES ONLY

I certify that the Life Assured has signed / put his/her thumb impression in my presence after admitting that all the answers to
Questions Nos 10 onwards of this form have been correctly recorded .

.. .
Signature or thumb impression of the Proposer. Signature of the Medical Examiner.

NB. Signature or thumb impression should be affixed in presence of Medical Examiner.

1492687171607
Merchant ID : D498741 IPIN:
000012
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300-12.00

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