Annexure 8

PROPOSAL FORM FOR LIC’s AROGYA RAKSHAK URN: HPF- 2

Branch Office………………………… Divisional Office…………………………

To be filled by agent:
1. D.O./CLIA/ Chief Organizer Code No / Mentor code & Mobile number :
2. Agent’s/Specified Person’s/DSA’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 the Principal Insured and other members to be insured

No. of lives to be covered under the policy (including Principal

Insured)

A Personal Details Principal Insured (Proposer)

1 Full Name (to be printed on Health Card)
2 Father’s Full name
3 Gender
4 Marital Status
5 Date of Birth
6 Age last birthday
7 Place/ City of Birth
8 Nature of Age Proof Submitted
9 Nationality/ Citizenship
10 Residential status Resident Indian / Non Resident Indian/ Foreign
National of Indian Origin/Overseas Citizen of India
11 Correspondence Address
House No.
City/ Town/ Village
District & State
Country
PIN Code
Tel. No. with STD Code
12 Permanent Address / Address outside India in case of NRIs
House No.
City/ Town/ Village
District & State
Country
PIN Code
13 KYC and AML
a Are you Income Tax Assessee
b PAN Number
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
c Proof of Identity
d ID number *
e Expiry date of Id :
f Address Proof Submitted
g Are You Registered under GST, if yes give GSTIN :
h CKYC number ( Central KYC Registry)
14 Educational Qualification and Occupation
a Educational qualification
b Present Occupation
c Source of Income
d Name of the present employer
e Exact Nature of duties
f Length of service
g Annual Income
h To be answered if employed in the Armed Forces
i Wing to which life to be insured belong
ii Rank therein
iii Date of last Medical Examination
iv Medical category after medical examination
v Were you ever below A-1 category? If so, when?

15 Others
a 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
.
b 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.
c 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.]

16 Details of Nominee and appointee (It is in the interest of the life to be assured to avail the facility of nomination)
Name and address of % Age Relationship If Nominee is minor Relationship Appointee’s
Nominee share with the , appointee’s full to the signature as a
Principal name, age and nominee token of
Insured address consent

17 Bank Details of Principal Insured

Bank Account details:
a) Type of Account-Savings / Current:
b) Your Account No :_____________________________________
c) MICR Code:__________________________________________
d) IFS Code:____________________________________________
e) Name and Address of your bank:____________________________________________________________
Attach a photocopy or cancelled cheque with the form

B Personal Details Other Member to Other Member to Other Member to

be Insured - 1 be Insured - 2 be Insured - 3
1 Full Name to be printed on Health
Card
2 Father’s Full name
3 Gender
4 Marital Status
5 Date of Birth
6 Age last birthday
7 Place/ City of Birth
8 Nature of Age Proof Submitted
9 Nationality/ Citizenship
10 Residential status
(Resident Indian / Non Resident
Indian/ Foreign National of Indian
Origin/Overseas Citizen of India)
11 Relationship between PI and other
member to be assured
12 Correspondence Address
House No.
City/ Town/ Village
District & State
Country
PIN Code
Tel. No. with STD Code
13 Permanent Address / Address outside India in case of NRIs
House No.
City/ Town/ Village
District & State
Country
PIN Code
14 KYC and AML
a Is life to be insured Income Tax
Assessee
b PAN Number
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
c Proof of Identity
d ID number *
e Expiry date of Id :
f Address Proof Submitted
g Is life to be insured Registered
under GST, if yes give GSTIN :
h CKYC number ( Central KYC
Registry)
15 Educational Qualification and Occupation
a Educational qualification
b Present Occupation
c Source of Income
d Name of the present employer
e Exact Nature of duties
f Length of service
g Annual Income
h To be answered if employed in the
Armed Forces
i Wing to which life to be insured
belong
ii Rank therein
iii Date of last Medical Examination
iv Medical category after medical
examination
v Was life to be insured ever below
A-1 category? If so, when?

16 Others
a Is life to be insured’s occupation
associated with any specific hazard
or does life to be insured take part
in hazardous activities or have
hobbies that could be dangerous in
any way? If yes , give details and
submit respective questionnaire .
b Has life to be insured ever been or
is 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.

c Is life to be insured a Politically

Exposed Person OR is 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.]

Signature Mobile No. E mail Id

Principal Insured

Other Member to be Insured - 1

Other Member to be Insured - 2

Other Member to be Insured - 3

Section - II: Details related to proposed Plan and Previous policies under health Plan
( Initial Daily Benefit will be “per life*” basis)

1 Mode of premium payment

2 Initial Daily Benefit chosen for
Principal Insured
Other Member to be Insured - 1
Other Member to be Insured - 2
Other Member to be Insured - 3
Note:
1. Default provision for Insured Spouse/Parent to become Principal Insured on exit of original PI from the
policy.
On the exit of original PI in the event of death or expiry of his/her cover (i.e. where expiry of cover shall be on
the Date of Cover Expiry of PI or on PI exhausting all the lifetime maximum Benefit Limits), the policy shall
continue with the surviving Insured Spouse as new PI along with other eligible surviving Insured(s). If there is
no Insured Spouse under the Policy; or if Insured Spouse has predeceased the PI; or if the Insured Spouse
has exited from the policy, the policy shall continue with elder of the surviving Insured Parents as new PI along
with other eligible surviving Insured(s).
The premium for such new successive PI would be based on the then applicable tabular premium rates for
Principal Insured and the age for calculation of revised premium rate will be his/her age at entry. However, the
existing level of cover in respect of the new PI shall remain unaltered as applicable to him /her.

2. * The total Initial Daily Benefit under all policies issued to an individual under this plan shall not
exceed Rs. 10,000/-

3 Whether You/Your Spouse want to avail Term Yes / No

Rider and / or Accident Benefit Rider ( Only
available for Principal Insured and spouse) , If yes
please specify below
a. Accident Benefit Rider Sum Assured PI : Spouse:
b. Term Assurance Rider Sum Assured PI: Spouse
4 Previous health Insurance policies under LIC’s Arogya Rakshak Plan( If more policies , separate addendum
may be used )
Life Policy No Initial Daily Benefit Lapsed/ In force
availed
Principal Insured
 Other Member to be Insured - 1
Other Member to be Insured - 2
Other Member to be Insured - 3
5 Details of all previous policies under Health and Life are to be given in Annexure ‘B’ in respect of each
life to be Insured under this proposal.
6 Principal Other Member to Other Member to Other Member to
Insured be Insured - 1 be Insured - 2 be Insured - 3
Has any proposal/
application for revival for life,
health or critical illness cover
been postponed, declined or
accepted on special terms?
(If yes, Give details)

7 Simultaneous Principal Other Member to Other Member to Other Member to

Proposals Insured be Insured - 1 be Insured - 2 be Insured - 3
Is any proposal for life or
health insurance under
consideration on life to be
insured with LIC or any other
company.
8 Is life to be insured
registered with LIC Portal:
Y/N
a. If yes, Give Customer Id
b. 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

Signatures of other Major Members to be insured Signature of the Principal Insured

i)……………………….
ii)……………………….
iii)………………………

Section-III

Personal and family details of health / habits

Details Principal Other Member to Other Member to Other Member

Insured be Insured - 1 be Insured - 2 to be Insured - 3
1 Please state exact height ( in cms) Height _____ Height _____ Height _____ Height _____
and weight ( in Kgs) ( without shoes) Weight _____ Weight _____ Weight _____ Weight _____
2 Is the life to be insured currently
taking any medication or drugs? Or
have you previously taken, any
medication or treatment for a
continuous period of more than 14
days for any condition, other than for
minor coughs, cold, flu, typhoid?
3 Has the life to be insured lost more
than 5 Kgs. of weight in the last 12
months except due to exercise or
weight loss programmes, If yes,
please state the reason for the weight
loss.
4 During the past 5 years, has the life
to be insured ever suffered from any
illness, disorder, disability or injury
which has required any form of
medical or specialized examination
(including X-ray, blood tests, ECG,
USG, CT/MRI, gynecological
investigations), Consultation,
hospitalization or surgery?
5 Has the life to be insured remained
absent from place of work, school or
college on grounds of health for more
than 7 days during the last 2 years? If
yes, give details
6 Has the life to be insured planned for
a surgery or is currently aware of any
medical condition that might require
medical advice/surgery in near
future?
7 Has the life to be insured ever suffered from or suffering from or undergone investigation in the past or been
advised to undergo investigation or treatment for the following ailments:
a. Hypertension/high blood
pressure
b. Diabetes or raised blood
sugar
c. Cardiovascular disease,
Palpitations, Heart attack,
stroke, chest pain
d. (i) Genitourinary diseases e.g.
Kidney disorder, Bladder
disorder, Urine abnormality,
renal stones, genital organ
disorder, Hydrocele / fistula /
piles
(ii) symptoms or ailment
relating to Prostate, Urinary
System or Reproductive
System or any other disorder
e. Cancer of any type or a cyst
or lump or growth of any kind
f. Mental Disorder e.g.
Depression, anxiety,
schizophrenia, or any other
mental, psychiatric or
nervous disorder
g. Endocrine diseases e.g.:
Thyroid or any other hormonal
disorder
h. Digestive disease e.g.: Liver
and gall bladder disorder,
gastric ulcer, bleeding from
intestine or any other disorder
of the digestive tract
i. Respiratory diseases e.g.:
Asthma, pneumonia,
bronchitis, tuberculosis,
persistent cough, or any other
disorder of the chest or lungs.
j. Musculoskeletal diseases
e.g.: Osteoporosis, prolapsed
disc, back or neck complaint,
 any physical
disability/deformity or other
disorder of the bones, joints,
arthritis, gout etc
k. Neurological diseases e.g.:
Fits, epilepsy, recurrent
headache, paralysis, stroke,
any other disease or disorder
of the brain, spinal cord or
nerves
l. Congenital Disorders
m. Blood disorder e.g. Anemia,
hemophilia, thalassemia
n. (i) Eye, Ear, Nose, Throat or
Skin disorders
(ii) Does the life to be insured
wear glasses?
If yes, please give power
of glasses
o. Has the life to be insured ever
been tested positive for HIV /
AIDS, hepatitis B or C or any
sexually transmitted disease?
p. Any other disease?
8 If answer to any of the questions mentioned in ‘7’ above is yes, please give details as below ( If hospitalized ,
enclose the discharge summary and all investigation papers along with the proposal form.)
a. Nature of disease / illness
b. Date of Diagnosis
c. Fully recovered (Y/N)
d. Still on treatment (Y/N), If Yes give
details of treatment
e. Name and address of Doctor/
Hospital
9 Family History
Does the life to be insured have a parent,
brother or sister who was or has been
diagnosed with heart disease, stroke,
diabetes, cancer, neurolgical/ mental
disorders or any hereditary disorder under
the age of 65 years ? If yes, please give
a. Name of the disease/condition
b. Relationship with the life to be
assured and
c. Date of diagnosis
d. Age at diagnosis
e. Date of death, if any
10 Habits
Does life to be insured smoke/consume
or ever smoked /consumed the following.
If yes, quantity consumed
a. Alcoholic drinks ( kind of alcohol and
pegs per day)
b. Narcotics
c. Any other drugs, If yes, which one
d. Tobacco in any form (Tobacco
product includes but not limited to
cigars, cigarettes, beedis, chewable
tobacco like Gutkha, flavored paan
masala, etc.) (If yes in sticks
/packets/ sachets/day or gms /day)
11 For Female Lives only
a Is life to be insured pregnant now? If yes
expected date of delivery
b Date of last delivery
c Has life to be insured had any abortion
or miscarriage or Cesarean section? If
so, give details
d Has life to be insured ever consulted a
gynecologist or undergone any
investigation, treatment for any gynaec
ailment? (If yes, give details)
e Has any of life insured’s children had any
congenital abnormality ?
12 Husband’s details ( Applicable for only female principal Insured)
a Husband’s full Name
b His Occupation
c His Annual Income
d Details of Husband’s health Insurance
Policy number Name of branch/ Division/ Name of the Sum Plan & Present status of the
insurer ( if other than LIC) from where Assured Term policy
policy has been taken

Signatures of other Major Members to be insured Signature of the Principal Insured

i)……………………….
ii)……………………….
iii)………………………

Section-IV : Declaration

DECLARATION BY THE PRINCIPAL INSURED AND OTHER MAJOR MEMBERS TO BE INSURED

I, do hereby declare that I am authorized to propose on behalf of these other persons and give consent on my behalf and
on behalf of all persons proposed to be insured

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the foregoing statements and
answers have been given by me in this proposal form alongwith Annexure ‘B’ 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 us 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.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board
approved underwriting policy of the insurer and that the policy will come into force only after full payment of the premium
chargeable. I understand that the Corporation reserves the right to accept /postpone/ drop / regret or decline this proposal
for health insurance .

I further declare that any change related to my/ other person to be insured’s health, occupation or any other adverse
circumstance after the submission of this proposal to the Corporation shall be conveyed in writing before the issuance of
the First Premium Receipt/communication of acceptance of risk. I also declare that I will inform about dropping,
deferment, acceptance at terms other than as proposed of any proposal/ revival of policy made to the Corporation or any
other insurance company. Any omission on my part to do so shall render this contract invalid.

I hereby give my consent for undergoing medical examination/tests including test for HIV as required by the Corporation

I, on my behalf and on behalf of all persons proposed to be insured, declare that I consent to the Corporation seeking
medical information from any doctor or hospital who/which at anytime has attended on the person to be insured/proposer
or from any past or present employer concerning anything which affects the physical or mental health of the person to be
insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be
insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I, on my behalf and on behalf of all persons proposed to be insured, authorize the Corporation to share information
pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of underwriting the
proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

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 hereby give my consent to receive phone calls, SMS/E mail on the above 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 premium and benefits under the policy are subject to taxes / duties/ charges in accordance with
the laws as applicable from time to time.

I, on my behalf and on behalf of all persons proposed to be insured do hereby declare that I have understood the plan
features and I have taken a personal and independent decision in an informed manner to take the plan in consultation
with the agent/ intermediary

Dated at ………………………………………On the……………………………… Day of …………………20

Witness:
(Signature, Name & Address)

Signatures of other Major Members to be insured Signature of the Principal Insured

i)……………………….
ii)…………………………….
iii)……………………………………………

Declaration by the person filling in the form (In case form is filled /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 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.”

Name of the Declarant:________________ Signature:____________________

Address of the Declarant:________________

I certify that the contents of the form have been fully explained to me by Mr/ Ms:______________.

Signatures of other Major Members to be insured Signature of the Principal Insured

i)………………………. ii)………………………… iii)…………………………

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 purposes 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.
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.’

SECTION 41 OF THE INSURANCE ACT, 1938 AS AMENDED BY INURANCE LAWS (AMENDMENT) ACT, 2015

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.
 AGENT'S CONFIDENTIAL REPORT / MORAL HAZARD REPORT

Agent's/FSE's Name & Address and Mobile number

Agency code
Club membership

I Information about the Principal Insured

a. Name of the Principal Insured :
b. Age of the Principal Insured :
c. Whether the terms and conditions of the proposed plan(s) have been
explained to Principal Insured and other members?
d. Whether the proposed plan matches the objectives of insurance of the
proposer/ life to be assured ?
e. How long do you know the Principal Insured ?
f. Are you related to him/her? If so, give details
g. What is the educational qualification?
h. Whether Principal Insured / other members or family member/s is/are
Politically Exposed Person (PEP) as per RBI guidelines?
[As per RBI guidelines PEPs are the individuals who are or have been
entrusted with prominent public functions in a foreign country.]
i. Are you satisfied that the Principal Insured / other members are not
connected with any terrorist activities ?
j. Whether KYC/ PMLA norms are fulfilled for the Principal Insured / other
members?
II Financial assessment by the Agent
a. Exact Source of Income
b. Are you personally satisfied with the financial standing of the Principal
Insured and justify the current proposal ?

III Previous insurance details including from other insurers

a. Did you discuss with the Principal Insured / other members the
status of Previous Policies and are you satisfied that no policy has
lapsed within the last three years?
b. Are you aware of any Proposal (or Revival of any policy) of the
Principal Insured / other members having been deferred, declined,
dropped or accepted at terms other than those proposed ?

IV Information about health , Habit and occupation/ avocation etc

a. What is the general state of health of the Principal Insured / other
members?
b. Do they have any physical deformity or Mental Retardation?
c. Do you have any knowledge of them having suffered from any illness or
injury or undergone any operation or medical investigation?
d. Physical Measurements and Identification Marks of the Proposer and other Members (beneficiaries) to be
insured under the proposal.
Member To Be Name Height Weight Identification Marks
Insured (cms) (kgs)
Principal Insured
Other Insured 1
Other Insured 2
Other Insured 3
Other Insured 4
Other Insured 5
Other Insured 6
e. Any other information

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

Place

Date: Signature of the Agent along with seal/ stamp

To be complete by the Development Officer /CLIA/Mentor)

I am satisfied with the identity of the Principal Insured and other members to be insured on the basis of my
independent enquiries. I hereby declare that the foregoing statements are true and correct to the best of my knowledge
and belief.

Date

Name and Designation/Standing (No. of Years) Signature

To be completed by ABMS/BM/ Sr. BM)

I am satisfied with the identity of the Principal Insured and other members to be insured on the basis of my
independent enquiries. I hereby declare that the foregoing statements are true and correct to the best of my knowledge
and belief.

Date
Name and Designation Signature
 PROPOSAL FOR LIC’s AROGYA RAKSHAK
PHOTO ADDENDUM FOR PREPARATION OF HEALTH IDENTITY CARDS Plan No. -------------

Members to be Insured Principal insured Other Insured 1 Other Insured 2 Other Insured 3
( In the same sequence ( Affix stamp ( Affix stamp ( Affix stamp ( Affix stamp
of details of size photograph) size photograph) size photograph) size photograph)
other member/s

i) Name

ii) DOB

iii) Gender
(Male/Female)
iv) Relationship

Members to be Insured Other Insured 4 Other Insured 5 Other Insured 6

( In the same sequence ( Affix stamp ( Affix stamp ( Affix stamp
of details of size photograph) size photograph) size photograph)
other member/s

i) Name

ii) DOB

iii) Gender
(Male/Female)
iv) Relationship

Specimen Signature of the Principal Insured:

For Office Use: Policy Number…………………………………………………………..

Total Number of Lives Covered…………………………………….
Division Name and Code……………………………………………..
Branch Name & Code.…………………………………………………

Check list:
1. Age Proof(s) of all the Members to be insured
2. Photographs of all the Members to be insured
3. Signature of the Principal Insured
 Annexure-A

PROPOSAL FOR LIC’s AROGYA RAKSHAK URN: HPF- 2

HEALTH DETAILS AND MEDICAL INFORMATION

(IN RESPECT OF OTHER MEMBERS TO BE INSURED)
(To be used if the total number of members to be insured excluding PI (in the proposal form) exceeds 3)

Section - I: Details of other members to be insured

A Personal Details Other Member to Other Member to Other Member to

be insured - 4 be insured - 5 be insured - 6
1 Full Name to be printed on Health
Card
2 Father’s Full name
3 Gender
4 Marital Status
5 Date of Birth
6 Age last birthday
7 Place/ City of Birth
8 Nature of Age Proof Submitted
9 Nationality/ Citizenship
10 Residential status
(Resident Indian / Non Resident
Indian/ Foreign National of Indian
Origin/Overseas Citizen of India)
11 Relationship between PI and other
member to be assured
12 Correspondence Address
House No.
City/ Town/ Village
District & State
Country
PIN Code
Tel. No. with STD Code
13 Permanent Address / Address outside India in case of NRIs
House No.
City/ Town/ Village
District & State
Country
PIN Code
14 KYC and AML
a Is life to be insured Income Tax
Assessee
b PAN Number
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
c Proof of Identity
d ID number *
e Expiry date of Id :
f Address Proof Submitted
g Is life to be insured Registered
under GST, if yes give GSTIN :
h CKYC number ( Central KYC
Registry)
15 Educational Qualification and Occupation
a Educational qualification
b Present Occupation
c Source of Income
d Name of the present employer
e Exact Nature of duties
f Length of service
g Annual Income
h To be answered if employed in the
Armed Forces
i Wing to which life to be insured
belong
ii Rank therein
iii Date of last Medical Examination
iv Medical category after medical
examination
v Was life to be insured ever below
A-1 category? If so, when?

16 Others
a Is life to be insured’s occupation
associated with any specific hazard
or does life to be insured take part
in hazardous activities or have
hobbies that could be dangerous in
any way? If yes , give details and
submit respective questionnaire .
b Has life to be insured ever been or
is 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.

c Is life to be insured a Politically

Exposed Person OR is 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.]

Signature Mobile No. E mail Id

Principal Insured

Other Member to be insured - 4

Other Member to be Insured - 5

Other Member to be Insured - 6

Section - II: Details related to proposed Plan and Previous policies under health Plan
( Initial Daily Benefit will be “per life*” basis)
1 Mode of premium payment
2 Initial Daily Benefit chosen for
Other Member to be Insured - 4
Other Member to be Insured - 5
Other Member to be Insured - 6
Note:
1. Default provision for Insured Spouse/Parent to become Principal Insured on exit of original PI from the
policy.

On the exit of original PI in the event of death or expiry of his/hercover (i.e. where expiry of cover shall be on
 the Date of Cover Expiry of PI or on PI exhausting all the lifetime maximum Benefit Limits), the policy shall
continue with the surviving Insured Spouse as new PI along with other eligible surviving Insured(s). If there is
no Insured Spouse under the Policy; or if Insured Spouse has predeceased the PI; or if the Insured Spouse
has exited from the policy, the policy shall continue with elder of the surviving Insured Parents as new PI
along with other eligible surviving Insured(s).

The premium for such new successive PI would be based on the then applicable tabular premium rates for
Principal Insured and the age for calculation of revised premium rate will be his/her age at entry. However, the
existing level of cover in respect of the new PI shall remain unaltered as applicable to him /her.

2. * The total Initial Daily Benefit under all policies issued to an individual under this plan shall not exceed
Rs. 10,000/-

3 Previous health Insurance policies under LIC’s Arogya Rakshak Plan ( If more policies , separate addendum
may be used )
Life Policy No Initial Daily Benefit Lapsed/ In force
availed
Other Member to be Insured - 4
Other Member to be Insured - 5
Other Member to be Insured - 6
4 Details of all previous policies under Health and Life are to be given in Annexure ‘B’ in respect of each
life to be Insured under this proposal.
5 Other Member to Other Member to be Other Member to be
be Insured - 4 Insured - 5 Insured - 6
Has any proposal/ application for
revival for life, health, or critical
illness cover been postponed,
declined or accepted on special
terms? (If yes, Give details)

6 Simultaneous Proposals Other Member to be Other Member to be Other Member to be

Insured - 4 Insured - 5 Insured - 6
Is any proposal for life or
health insurance under
consideration on life to be
insured with LIC or any other
company.
7 Is life to be insured registered
with LIC Portal: Y/N
a. If yes, Give Customer Id
b. 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

Signatures of other Major Members to be insured Signature of the Principal Insured

i)……………………….
ii)……………………….
iii)………………………
Section-III

Personal and family details of health / habits

Details Other Member to Other Member to Other Member to be

be Insured - 4 be Insured - 5 Insured - 6
1 Please state exact height ( in cms) and Height _____ Height _____ Height _____
weight ( in Kgs) ( without shoes) Weight _____ Weight _____ Weight _____

2 Is the life to be insured currently taking

 any medication or drugs? Or have you
previously taken, any medication or
treatment for a continuous period of more
than 14 days for any condition, other than
for minor coughs, cold, flu, typhoid?
3 Has the life to be insured lost more than 5
Kgs. of weight in the last 12 months
except due to exercise or weight loss
programmes. If yes, please state the
reason for the weight loss.
4 During the past 5 years, has the life to be
insured ever suffered from any illness,
disorder, disability or injury which has
required any form of medical or
specialized examination (including X-ray,
blood tests, ECG, USG, CT/MRI,
gynecological investigations),
Consultation, hospitalization or surgery?
5 Has the life to be insured remained absent
from place of work, school or college on
grounds of health for more than 7 days
during the last 2 years? If yes, give details
6 Has the life to be insured planned for a
surgery or is currently aware of any
medical condition that might require
medical advice/surgery in near future?
7 Has the life to be insured ever suffered from or suffering from or undergone investigation in the past or been
advised to undergo investigation or treatment for the following ailments:
a. Hypertension/high blood pressure

b. Diabetes or raised blood sugar

c. Cardiovascular disease, Palpitations,

Heart attack, stroke, chest pain
d. (i) Genitourinary diseases e.g.
Kidney disorder, Bladder disorder,
Urine abnormality, renal stones,
genital organ disorder, Hydrocele /
fistula / piles
(ii) symptoms or ailment relating to
Prostate, Urinary System or
Reproductive System or any other
disorder
e. Cancer of any type or a cyst or lump
or growth of any kind
f. Mental Disorder e.g. Depression,
anxiety, schizophrenia, or any other
mental, psychiatric or nervous
disorder
g. Endocrine diseases e.g.: Thyroid or
any other hormonal disorder
h. Digestive disease e.g.: Liver and
gall bladder disorder, gastric ulcer,
bleeding from intestine or any other
disorder of the digestive tract
i. Respiratory diseases e.g.: Asthma,
pneumonia, bronchitis, tuberculosis,
persistent cough, or any other
disorder of the chest or lungs.
j. Musculoskeletal diseases e.g.:
Osteoporosis, prolapsed disc, back
or neck complaint, any physical
 disability/deformity or other disorder
of the bones, joints, arthritis, gout etc
k. Neurological diseases e.g.: Fits,
epilepsy, recurrent headache,
paralysis, stroke, any other disease
or disorder of the brain, spinal cord
or nerves
l. Congenital Disorders
m. Blood disorder e.g. Anemia,
hemophilia, thalassemia
n. (i) Eye, Ear, Nose, Throat or Skin
disorders
(ii) Does the life to be insured wear
glasses?
If yes, please give power of glasses

o. Has the life to be insured ever been

tested positive for HIV / AIDS,
hepatitis B or C or any sexually
transmitted disease?
p. Any other disease?
8 If answer to any of the questions mentioned in ‘7’ above is yes, please give details as below ( If hospitalized ,
enclose the discharge summary and all investigation papers along with the proposal form.)
a. Nature of disease / illness
b. Date of Diagnosis
c. Fully recovered (Y/N)
d. Still on treatment (Y/N), If Yes give
details of treatment
e. Name and address of Doctor/
Hospital
9 Family History
Does the life to be insured have a parent,
brother or sister who was or has been
diagnosed with heart disease, stroke,
diabetes, cancer, neurolgical/ mental
disorders or any hereditary disorder under
the age of 65 years ? If yes, please give
a. Name of the disease/condition
b. Relationship with the life to be
assured and
c. Date of diagnosis
d. Age at diagnosis
e. Date of death, if any
10 Habits
Does life to be insured smoke/consume or
ever smoked /consumed the following.
If yes, quantity consumed
a. Alcoholic drinks ( kind of alcohol and
pegs per day)
b. Narcotics
c. Any other drugs, If yes, which one
d. Tobacco in any form (Tobacco
product includes but not limited to
cigars, cigarettes, beedis, chewable
tobacco like Gutkha, flavored paan
masala, etc.) (If yes in sticks
/packets/ sachets/day or gms /day)
11 For Female Lives only
a Is life to be insured pregnant now? If yes
expected date of delivery
b Date of last delivery
c Has life to be insured had any abortion or
miscarriage or Cesarean section? If so,
give details
d Has life to be insured ever consulted a
 gynecologist or undergone any
investigation, treatment for any gynaec
ailment? (If yes, give details)
e Has any of life insured’s children had any
congenital abnormality ?
12 Husband’s details ( Applicable for only female principal Insured)
a Husband’s full Name
b His Occupation
c His Annual Income
d Details of Husband’s health Insurance
Policy number Name of branch/ Division/ Name of the Sum Plan & Present status
insurer ( if other than LIC) from where Assured Term of the policy
policy has been taken

Signatures of other Major Members to be insured Signature of the Principal Insured

i)………………………….….
ii)…………………………….
iii)……………………………

Section-IV : Declaration

DECLARATION BY THE PRINCIPAL INSURED AND OTHER MAJOR MEMBERS TO BE INSURED

I , do hereby declare that I am authorized to propose on behalf of these other persons and give consent on my behalf and
on behalf of all persons proposed to be insured.

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the foregoing statements and
answers have been given by me in this proposal form alongwith Annexure ‘B’ 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 us 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.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board
approved underwriting policy of the insurer and that the policy will come into force only after full payment of the premium
chargeable. I understand that the Corporation reserves the right to accept /postpone/ drop / regret or decline this proposal
for health insurance .

I further declare that any change related to my/ other life to be assured’s health, occupation or any other adverse
circumstance after the submission of this proposal to the Corporation shall be conveyed in writing before the issuance of
the First Premium Receipt/ communication of acceptance of risk. I also declare that I will inform about dropping,
deferment, acceptance at terms other than as proposed of any proposal/ revival of policy made to the Corporation or any
other insurance company. Any omission on my part to do so shall render this contract invalid .

I hereby give my consent for undergoing medical examination/tests including test for HIV as required by the Corporation

I, on my behalf and on behalf of all persons proposed to be insured , declare that I consent to the Corporation seeking
medical information from any doctor or hospital who/which at anytime has attended on the person to be insured/proposer
or from any past or present employer concerning anything which affects the physical or mental health of the person to be
insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be
insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

I, on my behalf and on behalf of all persons proposed to be insured , authorize the Corporation to share information
pertaining to my proposal including the medical records of the insured / proposer for the sole purpose of underwriting the
proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
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 hereby give my consent to receive phone calls, SMS/E mail on the above 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 premium and benefits under the policy are subject to taxes / duties/ charges in accordance with
the laws as applicable from time to time.

I, on my behalf and on behalf of all persons proposed to be insured do hereby declare that I have understood the plan
features and I have taken a personal and independent decision in an informed manner to take the plan in consultation
with the agent/intermediary.

Dated at ………………………………………On the……………………………… Day of …………………20

Witness:
(Signature, Name & Address)

Signatures of other Major Members to be insured Signature of the Principal Insured

i)…………………………….
ii)…………………………….
iii)……………………………

Declaration by the person filling in the form (In case form is filled /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 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.”

Name of the Declarant:________________ Signature:____________________

Address of the Declarant:________________

“I certify that the contents of the form have been fully explained to me by Mr/ Ms:______________

Signatures of other Major Members to be insured Signature of the Principal Insured

i)………………………. ii)………………………… iii)…………………………

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 purposes 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
:
(e) The suggestion, as a fact of that which is not true and which the insured does not believe to be true;
(f) The active concealment of a fact by the insured having knowledge or belief of the fact ;
(g) Any other act fitted to deceive ; and
(h) Any such act or omission as the law specially declares to be fraudulent.
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.’

SECTION 41 OF THE INSURANCE ACT, 1938 AS AMENDED BY INURANCE LAWS (AMENDMENT) ACT, 2015

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.
 Annexure - B

(To be attached with proposal form for LIC’s AROGYA RAKSHAK)

Name of the Member to be insured __________________________________

Proposal Number ______________________________

A. DETAILS OF EXISTING HEALTH INSURANCE POLICIES INCLUDING (A) POLICIES SURRENDERED/LAPSED

(DURING LAST 3 YEARS) (B) IN FORCE HEALTH INSURANCE POLICIES ( C) POLICIES ACCEPTED WITH
MODIFIED TERMS OR WITH EXTRA PREMIUM
(If No. of policies are more, please attach a separate sheet)
Policy No. Insurance cos. Plan Sum Term Amount Year a. Whether a. Whether in
from where the & Assured assurance of of accepted as full force for
previous Term Rider Sum Acciden issue/ proposed at full sum
policies have Assured t Benefit Year ordinary assured.
been purchased taken of rates. b. If not in
with address (if Reviv b. If not, force, give due
purchased from al mention date of last
LIC, give name terms of premium paid
of BO/DO) acceptance or date of
(mention surrender
extra
premium
charged)

B. DETAILS OF EXISTING LIFE INSURANCE POLICIES INCLUDING (A) POLICIES SURRENDERED/LAPSED

(DURING LAST 3 YEARS) (B) IN FORCE POLICIES ( C) POLICIES ACCEPTED WITH MODIFIED TERMS OR
WITH EXTRA PREMIUM (If No. of policies are more, please attach a separate sheet)

Policy No. Insurance cos. Table Sum Term Amount a. Whether a. Whether in
from where the & Assured assuranc of Year accepted as full force for
previous Term e Rider Accident of proposed at full sum
policies have Sum Benefit issue/ ordinary assured.
been purchased Assured taken Year rates. YES/NO
with address (if of b. If not in
purchased from Reviv YES/NO force, give due
LIC, give name al b. If not, date of last
of BO/DO) mention premium paid
terms of or date of
acceptance surrender
(mention
extra
premium
charged)

Note: The above information is required in respect of each of the member to be insured under this proposal.

Signature of Principal Insured Signature of the other Member to be Insured, proposed for
insurance by the PI .