COLOUR

PHOTO OF THE
LIFE TO BE
FORM NO. 360 (Rev 2019)
PROPOSAL FOR INSURANCE ON THE LIFE OF MINOR LIVES ASSURED

Division: Branch Office:

INSTRUCTIONS TO LIFE TO BE ASSURED
1. This form is to be completed in BLOCK LETTERS by the proposer.
2. This form contains 4 sections namely Section I: Details of Proposer and Life to be assured Section II : Proposed
Plan Section III: Details of personal and family health and habits and Section IV : Declaration
3. Please read all the questions carefully and fill up the details truthfully.
4. Please ensure that you affix your signatures in all the places as required. In certain places more than one
signature is required. This is in your own interest.
5. If the proposer signs this proposal in vernacular or puts his/her thumb impression upon it, then the respective
declaration must be completed.
6. Answers should be legible. Questions should be answered in ‘Yes’ or ‘No’. (Strokes / dots / dashes / leaving the
questions unanswered will not be accepted). Details need to be provided in case of affirmative answers.
7. The proposer must countersign any cancellation or alterations made in this form. White ink must not be Used

To be filled by agent:
1. D.O./CLIA Code No / Mentor code & Mobile number :
2. Agent’s/Specified Person’s/DSE’s/Sup Agent’s Name ,Code No & Mobile number:
3. Licence No:
4. Date of Expiry:

For Office Use Only :

Inward no : Date
Proposal no : Amt of Deposit : B.O.C No: Date :

Section- I : Details of Proposer and Life to be assured

I. Personal Details Proposer Life to be assured

1 Name Prefix First Name Middle Name Last Prefix First Name Middle Name Last
Name Name

2 Father’s Full name

3 Mother’s Full Name
4 Gender Male / Female / Third Gender Male / Female / Third Gender
5 Marital Status
6 Spouse’s Full name
7 Date of Birth ____/______/________ ____/______/________
8 Age ** Years Years
** Depending upon the plan conditions, Age last birthday/Age nearer birthday shall be applied for the calculation
of premium
9 Place / City of Birth
10 Nature of Age Proof
Submitted
11 Nationality
12 Citizenship
13 Relationship between
Proposer & Life to be
Assured
14 Correspondence Address
House No.
City/ Town/ Village
District & State
Country
PIN Code
Tel. No.with STD
Code

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15 Permanent Address
House No.
City/ Town/ Village
District & State
Country
PIN Code
Tel. No.with STD
Code
16 Residential status Resident Indian / NRI / FNIO / OCI Resident Indian / NRI / FNIO / OCI
17 Address outside India ( Applicable only for NRI/FNIO/ OCI)
House No.
City/ Town/ Village
District & State
Country
PIN Code

II KYC& PMLA
1 Are you Income Tax Y/N Y/N
assesse
2 PAN
3 ID details( to be answered only if PAN card copy is not submitted)
* In case of Aadhaar only last four digits is to be given as Id number
Proof of Identity
ID number *
Expiry date of Id :
4 Address Proof
Submitted
5 Are You Registered
under GST, if yes give
GSTIN :
6 C KYC number (
Central KYC Registry)

III Educational Details of Life to be assured

1 Is the child studying? Y/N
2 If Yes , state the class
and /or type of course*
*Submit Latest school report card

IV Occupation of the proposer

1 Educational
qualification
2 Present Occupation
3 Source of Income
4 Name of the present
employer
5 Exact Nature of duties
6 Length of service
7 Annual Income

V Others
1 Is your occupation associated with any specific hazard or do you
take part in hazardous activities or have hobbies that could be
dangerous in any way? If yes , give details and submit
respective questionnaire .
2 Have you ever been or are currently being investigated, charge
sheeted, prosecuted or convicted or having pending charges in
respect of any criminal/civil offences in any court of law in India
or abroad ? If yes, give details.

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3 Are you a Politically Exposed Person OR are you a family
member or close relative of Politically Exposed Person?
[As per RBI guidelines PEPs are the individuals who are or have
been entrusted with prominent public functions in a foreign
country.]

VI Existing Insurance of Minor life ( Please give details of previous insurance taken from LIC as well as from
other insurers including policies surrendered / lapsed during last 3 years)

Note: 1. If space is not sufficient for all existing policies, please use separate sheet in the same format. it must be duly signed
by the life to be assured
2. Corporation normally does not entertain any fresh proposal for insurance where a policy has lapsed or has been converted
into paid up policy within the last 3 years.
1 Policy Number
2 Name of the Insurer/
Division/ Branch
3 Plan and Term
4 Sum assured
5 Date of Commencement
6 Date of Revival
7 Whether accepted at
ordinary rate, if not give
details
8 Medical/ Non medical
9 Whether Inforce
10 If not , Date of FUP/
Date of surrender
11 Has a proposal ( or an application for revival of a policy) on your life made to Yes/No Details
any office of the Corporation or to any other insurer ever been
a Withdrawn, Deferred, Dropped or Declined? if yes give details.
b Accepted with extra Premium or Lien? if yes give details.
c Accepted on terms other than those proposed? if yes give details.
d Have you during the past one year returned any policy of the Corporation as
the same was not acceptable to you? if yes give details.

VII a.Give below the particulars of all the assurance in full force on the lives of parents, brothers and sisters of Life
to be assured
Relation ship Policy Number Total Sum Assured
Father
Mother
Brothers
Sisters
b. Whether all the children are
insured equally? If No, please
mention reason for the same
Note: (Please give details of all questions in the space provided for the same.). If space is insufficient, attach a
separate sheet duly signed by Proposer

Mobile No of the Proposer:_______________________

E mail id of the Proposer :_______________________

Signature/ thumb impression of the Proposer

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 Section II : Proposed Plan

I Objective of Insurance : Saving / Risk Cover/ Saving and Risk Cover

II Plan , Rider and Sum assured selected by the Life to be assured( Riders are subject to availability under
the selected plan)
a Plan ** Term Premium Sum Proposed Mode of Do you wish to obtain If policy is
paying Term (Basic Sum Premium LIC’s Premium Waiver to be
Assured) Payment Benefit Rider? *** dated
(Yly/Hly/Qly/ back
NACH/SSS/ indicate
Single) date

b For SSS Policies :

i. Paying authority code and Dept No
ii. Badge or SR No
** In case of LIC’s JeevanTarun , Please fill the respective addendum which is the part of the proposal form.
***If LIC’s Premium Waiver Benefit Rider is opted , please fill Proposal form 300 separately.

III. To be answered only if proposing under “LIC’s Aadhaar Stambh “ or “ LICs Aadhaar Shila”
a. Total existing (excluding the proposal under consideration) sum assured under LIC’s Aadhaar
Shila/ LIC’s Aadhaar Stambh : ____________”
b. Is your life being proposed simultaneously under the same plan? Yes/No.
If “Yes”, give details : ____________
Note: The total Sum Assured under LIC’s Aadhaar Stambh or LIC’s Aadhaar Shila on an individual should not
exceed Rs. 3 lakhs.

IV Settlement Option
Do you wish to avail “Option to take Death Benefit In Installments” : Yes/ No
If ‘Yes’, Kindly fill the respective addendum which forms a part of the proposal form.
Note: You will have the option of altering the mode of receipt of payment of claim from lumpsum to installment
and vice versa during the policy duration till the point of claim.

V Simultaneous Proposals
a Is any other proposal on the life to be assured now being made to, or is Y/N
any other proposal or an application for revival of a policy on his life
under consideration in this or any other office of the Corporation or to
any office of any other insurer? If so, give details.
b Whether proposed simultaneously on the life of siblings / parents ? If yes, Y/N
give details

VI Consent
a Have you understood fully the terms & conditions of the plan you Y/N
propose to take?
b Whether the terms & conditions of the proposed plan and any other Y/N
information that you needed for matching your objectives of
insurancehave been explained to you by the agent?

VII Bank Details ( of the proposer in case of KMI and Partnership Proposals )
Bank Account details:
a) Type of Account-Savings / Current:
b) Your Account No :_____________________________________
c) MICR Code:___________________________d)IFSCode:_______________________________________
e) Name and Address of your bank:____________________________________________________________
Attach a photocopy or cancelled cheque with the form
VIII Are you registered with LIC Portal: Yes /No
If yes, give Customer ID ____________
If not, Please visit our site www.licindia.in and register yourself with LIC Portal after completion of this proposal to
avail the benefit of e services.

Signature/ thumb impression of the Proposer

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 Section- III : Health / habits of the life to be assured

I Personal Health
a Please state exact height ( in cms) and weight ( in Kg) ( without shoes) Height Weight
b During the last five years did life to be assured consult a Medical Y/N
Practitioner for any ailment requiring treatment for more than a week ?
If yes, give details
c Has life to be assured ever been admitted to any hospital or nursing Y/N
home for general check up, observation, treatment or operation? If yes,
give details
d Has life to be assured remained absent from school/ college/ Y/N
educational institute on grounds of health during the last 5 years? If
yes, give details
e Is the life to be assured suffering from or ever suffered or undergone investigation in the past or ever been
advised to undergo investigation or treatment for the following ailments:
Diseases Y/N Diseases Y/N
1. Lungs/ Respiratory Disease / Persistent 2. Hypertension, Hypotension, rheumatic fever,
cough, asthma, bronchitis, pneumonia, spitting pain in chest, breathlessness, palpitation, any
of blood etc disease of the heart or arteries?
3. Peptic ulcer/colitis, jaundice, anaemia, piles, 4. Any disease of kidney /prostate or urinary
dysentery, or any other disease of the system?
stomach, liver, spleen, gall bladder or
pancreas/ digestive disorder
5. Paralysis/epilepsy/ insanity/ tremors, 6. Hernia/ hydrocele, varicocele, fistula,
numbness, double vision, dizzy or fainting varicose veins, filariasis, gonorrhoea, syphilis
spells/ head Injury / insomnia/ nervous or any other venereal disease?
breakdown / any other disease of the brain or
the nervous system
7.Cancer/leukemia/lymphoma/ tumour / cyst/ 8. Any disease of ear, nose, throat or eyes,
Any other growth / lumps/ blood disorder including defective sight or hearing and
/enlarged glands discharge from the ears
9. Endocrine disorders such as Diabetes, 10. Bone / Joint/ Spine Disease/ Arthritis
Goitre, Thyroid etc or have you ever passed
sugar, albumin, pus or blood in urine
11. Mental Disorder (Depression/ Anxiety, 12. Chronic infections- Tuberculosis/ pleurisy /
etc.). Skin Disease/ skin eruption/ Leprosy.
13. Hepatitis or AIDS & HIV related condition 14. Any Operation, accident or injury/ any bodily
defect or deformity.
15. Any other disease?
f If answer to any of the questions mentioned in ‘e’ above is yes, please give details as below ( If hospitalized ,
enclose the discharge summary and all investigation papers along with the proposal form.)
Nature of disease / Date of Fully recovered Still on treatment (Y/N), If Name and
illness Diagnosis (Y/N) Yes give details of address of
treatment Doctor/ Hospital

II What has been usual state of health of life to be assured ?

III Family details

1 Has any of life to be assured's relations, living or dead, suffered
from or died of heart disease, stroke, high blood pressure,
diabetes mellitus, cancer, kidney disease, or any hereditary
disorder , insanity, epilepsy, or any contagious diseases such as
tuberculosis, Hepatitis, AIDS / HIV etc? If yes, please specify
a. Name of the disease
b. Relationship with the life to be assured and
c. date / year of death

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2 Family History
Living Dead
Age State of health Age at death Year/cause of death
Father
Mother
Brothers
Living
Dead
Sisters
Living
Dead
Spouse
Children
Living
Dead

Signature/ thumb impression of the Proposer

Section-IV : Declaration

DECLARATION BY THE PROPOSER

I.................................................(Name of the proposer) do hereby declare that the foregoing statement 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 dealt with as per provisions of Section
45 of the Insurance Act,1938 as amended from time to time.

And I further agree that if after the date of submission of the proposal but before the issue of First Premium Receipt
any change in the general health of the life to be assured or that of any members of his family occurs, 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 contract to be dealt with as per provisions of Section 45 of the Insurance Act, 1938
as amended from time to time.

I undertake to inform the Corporation immediately of any changes in KYC documents such as residence. I also give
my consent to share my data with Central KYC Registry and to receive phone calls , SMS/ E mail from Central KYC
registry in this regard

I understand that the Corporation reserves the right to accept /Postpone/ drop/ decline or offer alternate terms on this
proposal for life insurance .

I hereby give my consent to receive phone calls, SMS/E mail on the below mentioned registered number/ E mail
address from / on behalf of the Corporation with respect to my life insurance policy/regarding servicing of insurance
policies/enhancing insurance awareness/ notifying about the status of Claim etc.

I also understand that the terms and conditions including premium and benefits under the policy are subject to taxes /
duties/ charges in accordance with the laws as applicable from time to time.

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

Signature of witness...................
Name........................................
Occupation & address ____________________________________
..................................................... Signature / thumb impression of the proposer

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 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 or in case the proposer is person with disability (PWD) where he/she is not
able to fill the proposal form himself/ herself.)

“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 and proposer has affixed the thumb impression/ signature as below after fully
understanding the contents thereof.”

Signature of the declarant

Name of the Declarant:________________

Address of the Declarant:________________

“I certify that the contents of the form and documents have been fully explained to me by (Name, Designation,
occupation) Mr. / Ms.:________________ and I have understood the significance of the proposed contract.

Signature or Thumb impression of the life 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 the proposal form to the proposer in
______________language, and that the proposer has affixed the thumb impression above after fully understanding
the contents thereof.”

Signature: ____________________
Name of the Declarant: ________________
Address of the Declarant: _____________________

SECTION 45 OF THE INSURANCE ACT,1938

(1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years
from the date of the policy, i.e., from the date of issuance of the policy or the date of commencement of risk or the
date of revival of the policy or the date of the rider to the policy, whichever is later.
(2)A policy of life insurance may be called in question at any time within three years from the date of issuance of the
policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy,
whichever is later, on the ground of fraud :
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees
or assignees of the insured the grounds and the materials on which such decision is based.
Explanation I - For the purpose of this sub section, the expression “fraud” means any of the following acts committed
by the insured or by his agent, with the intent to deceive the insurer or to induce the insurer to issue a life insurance
policy :
(a) The suggestion, as a fact of that which is not true and which the insured does not believe to be true;
(b) The active concealment of a fact by the insured having knowledge or belief of the fact ;
(c) Any other act fitted to deceive ; and
(d) Any such act or omission as the law specially declares to be fraudulent.

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Explanation II – Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless
the circumstances of the case are such that regard being had to them, it is the duty of the insured or his agent,
keeping silence to speak, or unless his silence is, in itself, equivalent to speak.
(3) Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the
ground of fraud if the insured can prove that the mis-statement of or suppression of a material fact was true to the best
of his knowledge and belief or that there was no deliberate intension to suppress the fact or that such mis-statement of
or suppression of a material fact are within the knowledge of the insurer:
Provided that in case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is
not alive.
Explanation: A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the
formation of the contract, to be agent of the insurer.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance of the
policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy,
whichever is later, on the ground that any statement of or suppression of a fact material to the expectancy of the life of
the insured was incorrectly made in the proposal or other document on the basis of which the policy was issued or
revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees
or assignees of the insured the grounds and materials on which such decision to repudiate the policy of life insurance
is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material
fact, and not on ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the
insured or the legal representatives or nominees or assignees of the insured within a period of ninety days from the
date of such repudiation.
Explanation – For the purposes of this sub-section, the mis-statement of or suppression of fact shall not be considered
material unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show that
had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so,
and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on
subsequent proof that the age of the life insured was incorrectly stated in the proposal.

Signature or Thumb impression of the life to be assured

SECTION 41 OF THE INSURANCE ACT,1938

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 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 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 bonafide Insurance Agent employed by the insurer.

2) Any person making default in complying with the provisions of this section shall be liable for a penalty which
may extend to ten lakh rupees.

Signature or Thumb impression of the life to be assured Signature of the Agent

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FOR MINOR LIVES ONLY F.NO.3293A

With reference to the Proposal for Rs................on the life of my son/daughter/ Grand Son/ Daughter , I hereby agree
and undertake that if under the policy that may be issued, any payment is received by me by way of, loan(if
admissible) surrender, Cash Option, or for any other reasons whatsoever before the policy has vested in Life Assured,
I shall utilise the moneys thereby received for the benefit of the minor or his estate.

Signature of witness Signature/ thumb

impression of the Proposer

ADDENDUM TO PROPOSAL

“I understand and agree that the policy shall automatically vest on the Life Assured on the policy anniversary
coinciding with or immediately following the completion of 18 years of age and shall on vesting be deemed to be a
contract between the Corporation and Life Assured.”

Dated at ____________on the ___________day of ______________20 _________

________________________ ___________________________________

Signature of Witness Signature or Thumb impression of the Proposer

Name___________________
Occupation_______________
Address_________________

Addendum to Proposal Form

(To be obtained by the Proposer)

LIC’s JeevanTarun

Proposal No:

I _____________________________ understand that the following four Options are available for Survival and
Maturity benefit under this plan. Considering the future requirements of my child I have opted for Option ____ (1/2/3/4)
under this proposal.

Further, I understand that once an Option is chosen the same shall not be altered and shall become a part of the
Policy Contract.

Options available under the plan:

Option 1: No survival benefit payable during the policy term and entire 100% of Sum Assured along with vested
Simple Reversionary Bonuses and Final Additional Bonus, if any, shall be payable on maturity.
Option 2: Annual payment of 5% of Sum Assured every year starting from policy anniversary coinciding with or
following the completion of 20 years of age and thereafter on each of the next 4 policy anniversaries shall
be payable. The balance of 75% of Sum Assured along with vested Simple Reversionary Bonuses and
Final Additional Bonus, if any, shall be payable on maturity.
Option 3: Annual payment of 10% of Sum Assured every year starting from policy anniversary coinciding with or
following the completion of 20 years of age and thereafter on each of the next 4 policy anniversaries shall
be payable. The balance of 50% of Sum Assured along with vested Simple Reversionary Bonuses and
Final Additional Bonus, if any, shall be payable on maturity.
Option 4: Annual payment of 15% of Sum Assured every year starting from policy anniversary coinciding with or
following the completion of 20 years of age and thereafter on each of the next 4 policy anniversaries shall
be payable. The balance of 25% of Sum Assured along with vested Simple Reversionary Bonuses and
Final Additional Bonus, if any, shall be payable on maturity.

Date: Signature or Thumb Impression of Proposer

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 Addendum to Proposal Form for Option to take Death Benefit in Instalments

(To be furnished by the Life Assured )

Proposal No.

Do you wish to avail Option to take Death Benefit in Instalments under the proposal ?

YES/ NO

If yes, please Tick/Strikeout (if not applicable) the following:

1. Period forOption to take Death Benefit in Instalments (in years): 5 / 10 / 15

2. Whether Option to take Death Benefit in Instalments is required for: Full / Part of the benefit proceeds
If in part, specify the amount/ percentage of the benefit proceeds:
Absolute amount: -----------------
Percentage of benefit proceeds: -----------------
3. Mode of Instalment payment: Yearly / Half-Yearly / Quarterly / Monthly

If the Net Claim Amount is less than the required amount to provide the minimum instalment amount (as mentioned
below) as per the option exercised by the Proposer/Life to be Assured, the claim proceed shall be paid in lump sum
only.

Minimum
Mode of Installment installment amount
payment (Rs)

Rs. 5,000/-
Monthly
Rs. 15,000/-
Quarterly
Rs. 25,000/-
Half-Yearly
Rs. 50,000/-
Yearly

Date and Place:

Signature of the Life Assured

Name of Life Assured

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