CONTACT DETAILS FORM

Form no CRM /19-20/001 Date : -------- ---------- ----------------------

To

The Branch Manager,

LIC Of India,

Branch : -------------------------------------------------------------

Dear Sir / Madam,

Re : Contact details - mobile no. and email id of my policies.

I hereby submit my contact details (mobile no, email id & Pincode ) and voluntarily give my consent to
link the to all my below mentioned LIC Policies for sending Policy related communications.

Policy Nos : ---------------------------------------- ----------------------------------- ---------------------------------------

----------------------------------------- ----------------------------------- ---------------------------------------

Mobile No : ------------------------------------------------------------------------------pincode -------------------------------

Email id : -----------------------------------------------------------------------------

Yours faithfully,

(Signature of the Policy Holder)

Name of the Policy Holder ---------------------------------------------------------------------