FORM NO.

3260, ANNEXURE-A

____________________Division
Branch ________________________
STATEMENT TO BE SUBMITTED BY THE PROPOSER / AGENT / DEV. OFFICER WHEN A
STANDARD AGE PROOF VIZ, SCHOOL/UNIVERSITY/BIRTH CERTIFICATE IS NOT
SUBMITTED ALONG WITH THE PROPOSAL.
1. Name of proponent
2. Place and date of birth

5. Nature of age proof submitted

qualification and year of

Leaving School or College
7. Reasons for not submitting a standard proof of age
(i ) If the proponent is educated, state why a School/
University Certificate is not submitted
(ii) The reason why birth certificate cannot be
submitted.
(iii) If the proponent is in service, state why an extract
from service register cannot be produced.
(iv) If the submitted age proof is horoscope state
reason for the same.
declaration or self declaration state reasons for the
same.
I hereby agree that the foregoing questions and answers shall form part of the proposal for Insurance made by me
to the Life Insurance Corporation of India on _____________and they shall be of the same effect as if contained
in the original proposal.
Dated at _________________ on the__________________ day of ___________ 20

Signature of the Agent.

(Signature of the proposer).
I have discussed the question of standard proof of age with the proposer, I am satisfied that he cannot submit a
standard proof of age for the following reasons:
I further certify that according to my estimation his apparent age is __________________

(Signature of the Agent)

I have discussed the question of standard proof of age with the proposer and I am satisfied that be cannot submit
a standard proof of age for the following reasons:
I further certify that according to my estimation, his apparent age is __________________
(Signature of Dev. Officer)

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