LIFE INSURANCE CORPORATION OF INDIA

ENGINEERING DEPARTMENT,
CENTRAL ZONAL OFFICE
“JEEVAN SHIKHA BUILDING” 60-B, HOSHANGABAD ROAD, BHOPAL 462011

FORM FOR EMPANELMENT

OF

CONTRACTORS
 WEB SITE ADVERTISEMENT & ENROLMENT FORM

LIFE INSURANCE CORPORATION OF INDIA

ENGINEERING DEPARTMENT
CENTRAL ZONE
FORM FOR ENROLMENT OF CONTRACTORS

I / We ________________________ am / are desirous of being enrolled on

list of contractors for __________________________________________________
_________________________________________ and hereby apply for the same.

Sl. Name of Work Please mention the work

No. for which applied.
1

I / We give the following details for your consideration.

Sl.no QUERY ANSWER

1 Name of the firm :

2 Address

3 PAN No

TIN No.

VAT Registration No.

Service Tax Registration No.

4 Contact Details Office Phone No.

Residence
Phone No.

Mobile No.
 Fax No.

Email
5 Telegraphic Address, if any

6 Month and year in which the firm

was established in present name

7 Particulars of old firm (if present

firm is new) if main partners of the
present firm were working as
construction contractors, in some
other name in the past (The
partnership deed of old firm be
enclosed).
8 Particulars of sister construction
firms, if any :

9 i) What is the constitution of

firm viz. Sole Proprietor,
Partnership, Pvt. Ltd., Public Ltd.,
etc.

ii) Enclose copy of partnership

deed, Articles of Association or
Affidavit in case of sole
proprietorship as per
Annexure A-1.

iii)Fill-in enclosed Annexure A-2.

10 Fill and enclose Annexure B giving

details of enrolment with LIC of
India in the past and with other
organizations

11 Has the applicant or his partners or

Directors been black listed in the
past by any Central or State
Govt.Deptt./Organisation

12 i) Annual Turn Over for last four

years (enclose documentary YEAR Rs. in Lakh
evidence or proof to support
i 2012-13
figures)
ii 2013-14
 iii 2014-15

iv 2015-16
ii) What evidence of proof is
enclosed to support the amounts of
yearly turnover
iii) Enclose latest income tax Certificate enclosed for Assessment
clearance Certificate year _________

13 i) Name and complete postal

address of bankers

ii)Enclose solvency certificate

indicating amount (The certificate
should not be more than 3
months old).
iii)Bank Guarantee limit with i) Rs.________ Lac with __________
Various banks
ii) Rs.________ Lac with __________
iii) Rs.________ Lac with _________

TOTAL
14 i) Enclose list of immovable
properties with complete postal
addresses, full description &
reasonable market value of
property duly supported by
certificate of D.M./Collector/First
Class Magistrate/ approved valuer.
ii) Whose supporting certificate Rs._______________________
is enclosed
of ________________________
Date ______________________
15 i)Particulars of movable properties
along with Banker’s reference
Value of tools & plants Rs.
Other Assets Rs.
Total Rs.
ii) Whose reference is
enclosed?
16 Fill in and enclose list of tools &
plants as per Annexure-C
enclosed.
17 Fill in & enclose Annexure-D giving
full particulars about major works
completed during past Four
 years NOTE: List of only those
works which are carried out by
firm requesting for enrolment is
to be given. Work completion
certificate for qualified projects
must be notarized with address
& contact numbers of issuing
authority
18 Work in Progress:
i) Whether full details of major
work on hand given in Annexure
‘E’ Note: The details must be
notarized .
ii) Are copies of work orders for
such large works enclosed
19 Whether full information regarding
permanent technical staff employed
given in Annexure ’F’

20 i)How do you normally carry out

works of S,I,T,C of modular UPS
installations.

ii) Who is the license holder

and what his experience of this
work is.

21 i) How do you normally get

work of Substation works electrical
installations carried out
ii) Who is the license holder &
what is his experience

22 Any other information the

applicant might like to give

Note: a. For working contractors of LIC of India which means the Contractors who are
executing the similar nature of jobs at present and/or executed the jobs in LIC during
last four years, the above criteria may be relaxed by 15%.
b. All contractors must have the Service tax registration certificate.
 DECLARATION

I/We agree to notify the officer accepting this application and registering
my/our names on list of contractors of Life Insurance Corporation of India, of any
changes in the foregoing particulars as and when they occur and to verify and
confirm these annually on 1st January.

I/We understand and agree that the appropriate Life Insurance Corporation of
India Authority has the right as he may decide, not to issue tender form in any
particular case and also to suspend, remove or blacklist my/our name from Life
Insurance Corporation of India list of contractors in the event of my/our furnishing
false particulars in the enrolment form or submitting non-bonafide tenders or for
technical or other delinquency in regard to which the decision of appropriate Life
Insurance Corporation of India Authority shall be final and conclusive.

I/We certify that the particulars furnished in the enrolment forms are correct
and that should it be found that I/We have given a false certificate or that if I/We fail
to notify the fact of my/our subsequent amalgamation with another contractor or firm,
the Life Insurance Corporation of India may remove my/our name from the list of
contractors and any contract that I/We may be holding at the time may be rescinded.

PLACE :

DATE : SIGNATURE OF CONTRACTOR

: FOR OFFICE USE ONLY :

ENROLMENT FORM NO._________________ ISSUED TO

_________________________

NOTE: THE FILLED IN ENROLMENT FORM SHOULD REACH IN THE

OFFICE ON OR BEFORE 28/11/2016.

SIGNATURE OF ISSUING OFFICER

 ANNEXURE – A1

AFFIDAVIT

(On Non Judicial Stamp paper of appropriate value in case the individual who is the
sole proprietor of the firm)

I ……………………………………………………………………………………….
s/o ………………………………………………… age …………….. years, occupation
business r/o …………………………………………………… do hereby state on oath
as under:

That I am residing in ……………………………………………………… locality

of District …………………………………… since last ……………….. years.

That I am the sole proprietor of a proprietary concern name and style as

“……………………………………………………..” having it’s office at
………………………… District …………………………. dealing in business of
Government, civil contracts and ancillary works attached therefore.

Hence this affidavit.

Deponent _________________

Note: This Affidavit should be notarized.

 ANNEXURE A2

LIFE INSURANCE CORPORATION OF INDIA

CONSTITUTION OF FIRM – SOLE

PROPRIETORSHIP/PARTNERSHIP/LTD.CO./OTHER

DETAILS OF CONSTITUTENTS

Sr. Name of sole Age Share Technical Experience Whether power

No partner or Director / Year As As of attorney
. other High Officials to Employe contract Holder
Year e or
1 2 3 4 5 6 7 8

SIGNATURE OF CONTRACTOR
 ANNEXURE – B

LIFE INSURANCE CORPORATION OF INDIA

PARTICULARS OF ENROLMENT WITH LIC AND OTHER ORGANIZATION

I. ENROLMENT WITH LIC :

Name of works for 1)

Which enrolled by 2)
L.I.C. in the past 3)
4)
Sr. Nos. for which tenders were submitted :
Sr. Nos. for which work-order was received:

II. ENROLMENT WITH OTHER ORGANISATIONS:

Sr. Name & Address of FIRST TIME LAST RENEWAL OR ENROLMENT

No. Authority with whom ENROLMENT
you are enrolled
Year Is copy Year Class or Limit Is copy
to of letter to Categor (Rs. in of letter
year enclose year y Lac) enclose
d d
(1) (2) (3) (4) (5) (6) (7) (8)

SIGNATURE OF CONTRACTOR
 ANNEXURE – C

LIFE INSURANCE CORPORATION OF INDIA

PARTICULARS OF SHUTTERING TOOLS AND PLANT

Sr. Item Specification Quantity Estimated Remarks

No Value
.
(1) (2) (3) (4) (5) (6)
1. a) Shuttering plates
b) Shuttering
Wooden Planks
c) Wooden props
d) Steel props

2. Concrete Mixers
3. Concrete Vibrators
i) Petrol Driven
ii) Electric Driven

4. Tower Hoist
5. Trucks
6. Welding Equipments
7. Pump-Sets
8. Floor-Polishing
Machine
9. Cranes
10. Others

IGNATURE OF CONTRACTOR
 ANNEXURE – D

LIFE INSURANCE CORPORATION OF INDIA

LIST OF MAJOR WORKS COMPLETED DURING LAST FOUR YEARS

Sr. Name and Complete Postal Order Value of Commen- Comple Penalty
No. Address of work as cement of -tion of levied for
Site of Owner Authority Ref. No. Contract Is copy per final work work delay of
Work & under & Date Amount enclosed bill (Rs. month month comple-
Nature of whom (Rs. in in Lac) Year Year tion, if any
Work work was Lac)
(1) (2) (3) carried
(4) (5) (6) (7) (8) (9) (10) (11)

SIGNATURE OF CONTRACTOR
 ANNEXURE – E

LIFE INSURANCE CORPORATION OF INDIA

LIST OF WORK IN HAND

Sr. Name and Complete Postal Address of Order Date of Scheduled Progress made
No. commence date of and expected
Site of Owner Authority Ref. No. Amount Is copy -ment of completion date of
Work & under whom & Date (Rs. in enclose work of work completion and
Nature of work was Lac) d reasons for
Work carried out delay, if any

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

NOTE :- To enable us to process your application quickly, please ensure that complete Post Address including Pin code and Telephone
Numbers /Fax numbers/ e-mail address etc. are furnished under Column No. 2, 3 & 4 above.

SIGNATURE OF CONTRACTOR
 ANNEXURE – F

LIFE INSURANCE CORPORATION OF INDIA

PARTICULARS OF PERMANENT TECHNICAL STAFF

Sr. Name Designation Age Academic Service Details of

No Qualification with the Experience
. Firm Year to Year
(1) (2) (3) (4) (5) (6) (7)

SIGNATURE OF CONTRACTOR
 ANNEXURE – G

LIFE INSURANCE CORPORATION OF INDIA

ANNUAL TURNOVER FOR THE LAST FOUR YEARS

Sl.No. Financial Year Total Contract IT Certificate Audited Balance

(1) (2) amount received enclosed Sheet copy
(Rs. In Lac.) Yes/No enclosed Yes/ No
(3) (4) (5)

1 2012-13

2 2013-14

3 2014-15

4 2015-16

SIGNATURE OF CONTRACTOR

ANNEXURE – H
CHECKLIST FOR ENROLMENT:

Sr. No. Description of Enclosure Refer Item of form

1. Partnership deed / Articles of 9 (ii)
Association / Affidavit ()
() Annexure A-1
2. Annexure (A-2) as supplied 9 (ii)
(Particulars of Partners)
3. Annexure – E (as supplied) 10 (Particulars of enrolment in
LIC and other Organization)
4. Proof of Turnover 12 (ii)

5. Latest I.T.C.C. 12 (iii)

6. Solvency Certificate 13 (ii)

7. Certificate of Bank Guarantee 13 (iii)

8. Immovable Property Certificate 14 (ii)

9. Movable Property reference 15 (i)

10. () Annexure ‘C’ (as supplied) 16 (Particulars of shuttering

tools/ plant)
11. () Annexure ‘D’ (as supplied) 17 (List of major works
completed during last 4 years)
12. () Annexure ‘E’ (as supplied) 18 (List of work in hand)

13. () Copies of work order 18 (ii)

14. () Annexure ‘F’ (as supplied) 19 (Particulars of permanent

technical staff)
15 () Annexure ‘I’ (as supplied) For Tick marking on
categories under each works.

SIGNATURE OF CONTRACTOR