Life Insurance Corporation of India

____________ Division

DECLARATION

To be made by the Parents/Guardian of the Life Assured under

Jeevan Kishore / Children's Money Back Policy.

We declare that our son/daughter ...............................................

..............................................Kumari / Master........................................

born on .........................................day of ................................................

200......... is in good health and is studying in .......................................

standard in the school, the name and address of which, are given

below:

Name and Address of the School

Signature and name of the

Father/ Guardian

Signature and Name of the

Mother