Index

INDEX
List of Divisional Office (New Business) Forms (Except Policy Forms)
Proposal / Policy Clauses
Sr Clause Description Form No

No
1 1 Diminishing Lien Clause 3121
2 2 Constant Lien Clause 3122
3 4b Special Clause for female lives 3124 B
4 10a Special Minority Clause 3130 A
5 11 War and Aviation Clause 3131
6 13 Special War and Aviation 3133
Clause
7 14 Change of Occupation Clause 3134
8 20 Premium Waiver Benefit 3140
Clause
9 20A Premium Waiver Benefit 3140A
Clause
10 20B Family Benefit Rider Clause 3140 B
11 22 SSS Clause other than LIC 3142
employees
12 23 Special Clause for policies 3143
effected under M.W.P.Act
13 23 A Special Clause for policies 3143 (A)
18 31 Applicable to policies relating 3151
to LIC employees -SSS policies
19 32 Applicable to policies relating 3152
to LIC employees – other than
SSS policies
20 34 Special Clauses for policies 3154
effected under the MWP Act
effected under M.W.P
A ct
1
effected under M.W.P
A ct
effected under M.W.P Act
24 40 Endorsement by proposer on 3194
the back of Policy appointing
Central Bank Executor and
Trustee Co.as special Trustees
in M.W.P.A cases and Bank’s
consent.
25 46 Restrictive AB clause
26 53 Instalment premium inclusive
of Health extra
27 54 Restirctive Clause for PDB &
EPDB
28 55 Multiple Nominations
29 56 Minor Nominee with
Appointee
30 59 Endorsement by proposer on 3196
the back of Policy appointing
Canara Bank as Trustees under
M.W.P.A cases
31 65 Special Aviation Clause 3214
(Amateur Pilots)
32 66 Special Aviation Clause 3215
(Civilian Glider Pilots)
33 67 Restrictive Clause 3216
(Paratroopers)
34 69 Clause for payment of extra 3218
premium for the first few years
only from commencement
35 70 M.W.P.Act Clauses 3219
36 72 Applicable to single premium 3226
policies where Accident
Benefit is allowed.
37 74 Diver’s Clause 3228
38 75 War risks exclusion clause in 3229
case of Submarine personnel
39 76 CDA subject to satisfactory 3230
medical evidence at vesting
date
40 77 M.W.P.Act Clauses 3219 A
41 78 M.W.P.Act Clauses 3219 B
42 79 M.W.P.Act Clauses 3219 C
43 85 Exclusion Clauses for Accident 3188
Benefit to persons engaged in
hazardous
44 86 Exclusion Clause for sum
2
assured to person engaged in
Hazardous occupation but who
do not want to pay occupation
extra
ECR clause
AGE PROOF
Sr No Form Description
No
1 3260 Statement in respect of proposals where standard age proof is not
submitted
2 3261 Form of Age Declaration (Elder’s)
3 5096(R) A declaration of age by proposer (merged) 3179-A
4 5220 Self declaration for age on stamped paper
MEDICAL QUESTIONNAIRES
Sr No Description Form No
1 Asthama Questionnaire 3322
2 Bronchitis Questionnaire 3323
3 Central Nervous system Questionnaire (to be completed 3334
by the medical examiner)
4 Chest Pain Questionnaire (to be completed by the life 3333
assured)
4 Deformity Questionnaire
5 Diabetic Questionnaire (to be completed by the proposer) 3328
6 Diabetic Questionnaire (to be completed by Proposer’s 3329
Medical Attendant)
7 Epilepsy Questionnaire 3340
8 Filariasis Questionnaire 3332
9 Gall-Bladder Disease Questionnaire 3327
10 Gastric or Duodenal Ulcer (with operation) 3324
Questionnaire
11 Goitre Questionnaire (with operation) 3330
3
12 Goitre Questionnaire (without operation) 3331
13 Hearing Questionnaire
14 Hernia Questionnaire
15 Hypertension Questionnaire ( to be completed by the 3339
proposer)
16 Hypertension Questionnaire ( to be completed by the 3339A
proposer’s medical attendant)
17 Indigestion, Dyspepsia, Gastric or Duodenal Ulcer (Not 3325
operated) Questionnaire
18 Kidney Disease, Colic or stone etc Questionnaire 3326
19 Musculoskeletal Questionnaire
20 Personal Statement regarding health (DGH)
21 Pleurisy Questionnaire 3337
22 Renal Transplant Questionnaire
22 Tuberculosis Questionnaire 3336
23 Tumour Questionnaire
OCCUPATION QUESTIONNAIRES
1 General Occupation Questionnaire LIC03-500
2 Query Form for Army Personnel LIC03-501
3 Aviation Questionnaire for Services aviation personnel LIC03-502
4 Aviation Questionnaire for Civil aviation personnel LIC03-503
5 Civil Gliding Questionnaire LIC03-504
6 Query Form for Navy Personnel LIC03-505
7 Diving (Armed Services and Commercial) Questionnaire LIC03-506
8 Merchant Marine Questionnaire LIC03-507
FINANCIAL QUESTIONNAIRES
1 ACR cum MHR 380/3251
2 Agricultural Income Proof
3 Chartered Accountant’s certificate
4 Employer- Employee Scheme Questionnaire
5 Female Category I addendum
6 Female Category III (Widows) Addendum by DO
7 HUF Addendum
8 Keyman Questionnaire
9 Board Resolution for keyman insurance
10 Addendum to Proposal for assurance on the lives of minors
and Non-earning Major lives
11 Specimen of Supplementary Deed of Partnership
12 Personal Financial Questionnaire
4
13 Spl MHR Annexure A and B
NRI QUESTIONNAIRES
1 Procedure for completion of proposal form of Mail Order Annexure 1
Business (Medical Business)
2 Agent’s Confidential Report / Moral Hazard Report for Mail Annexure 2
Order Business
3 Special Questionnaire for NRIs (to be completed by employer Annexure 3
or personal physician)
4 Questionnaire to be completed by NRI Annexure 4
5 Life Insurance Memorandum (LIM) i.e. conditions on which Annexure 5
proposals are entertained by the Corporation
6 List of countries whose proposals may not be entertained / Annexure 6
entertained on some conditions
7 NRI Questionnaires
LETTERS TO PROPOSERS/POLICY HOLDERS

Sr No Form No Description
1 3107 Postponement Letter
2 3108 Rejection Letter
3 3109 Requirement Letter
4 3110 Letter in respect of cases accepted otherwise than as proposed
5 3162 Letter regarding proposal signed in a different language
6 3164 Letter to medical examiner regarding incomplete medical reports
7 3168 Letter suggesting appointment of new trustees other than a
beneficiary in M.W.P Act cases
8 3170 Letter to Proposer returning age proof
9 3179 Consent letter
10 3181 Letter to proposer refunding deposit
11 3185 Letter to proposer regarding dishonoured cheque
12 3193 Addendum to proposal when the proposal form is completed in
one language but signed in a different language.
13 Decalration to be made by the proposer under Jeevan Vishwas
Plan
14 3232 Letter to Policy holder with a Provident Fund policy
15 3234 Letter to be sent with policy in case of incomplete Nomination/
Assignement
16 3239 Letter regarding options available to be sent with policies
providing for options
17 3242 A Letter in reply to the letter regarding non-receipt of policy by the
policy holder
18 3242A Acknowledgement to policy holder that his proposal form has
5
(Annexure been sent to higher office
A)
19 3242 A Letter to policy holder for cooling off period
(Annexure
B)
20 3243 Letter dispatching policy returned by postal authorities
21 3244 Letter to Post Office asking them to investigate non-receipt of
policy
22 3245 Letter to Development Officer / Agent regarding policy returned
by the post office.
23 3892 Letter to be written to the proposer while forwarding to him the
policy prepared under M.W.P.Act where any of the above
institutions or trustees.
24 3893 Letter to be written by the proposer to the institutional trustee
25 3895 MWP
REPORTS
1 3311A Glucose Tolerance Test of Urine – Format of the report
2 Opthalmic Report
3 3310 Report of Fluoroscopic Examination (Screening)
4 3315 Report on X-Ray of Caecum and Colon (Barium Enema)
5 3317 Report on Cholecystography
6 3313 Report on X-Ray (Plain) of Genito Urinary Tract (K.U.B.Area)
7 3316 Report on Intravenous Pyelography
8 3314 Report on X-Ray of Stomach & Duodenum (Barium Meal)
9 3321 Report on examination of Sputum
10 3335 Report on examination of Stool
11 3338 Special B.S.T. Report
12 3341 rev Report of a gynaecologist in the case of pregnant ladies
13 LIC03-001 FMR
14 Juvenile FMR
15 LIC03-002 Rest Electrocardiographic examination report form
16 LIC03-003 Report on CTMT
17 LIC03-004 Report on Haemogram
18 LIC03-005 Report on Lipidogram
19 LIC03-006 Blood Sugar Tolerance report
20 LIC03-007 Report on SBT-12
21 LIC03-008 Report on SBT-18
22 LIC03-009 Routine Urine Analysis
23 LIC03-010 Report on X-Ray of Chest
24 LIC03-011 Report on Elisa for HIV
25 LIC03-012 Physician’s Report
6
MISCELLANEOUS FORMS
1 400 Joint Life Declaration
2 3111 Acceptance advice in P.F.cases
3 3112 Acceptance Letter cum F.P.Receipt
4 3112 (a) Acceptance Letter F.P.Receipt for annuities
5 3113 & First Premium Commission Voucher and copy of FPR
3114
6 3116 Declined Card Slip
7 3166 Extract from Medical Report and Personal Statement
8 3207 Policy Despatch Register
9 3233 Notice of Assignment enclosed with a Provident Fund Policy
10 3237 Form of Nomination under a Joint Life Policy
11 3237 A Form of Nomination under a Jeevan Sathi Policy
12 3248 Specimen of Post card to be sent at the time of dispatch of the
policy for second time
13 3264 Form of Nomination – Ordinary
14 3265 Form of Nomination for Minor Nominee
15 3293 A Undertaking by proposer in respect of policies under risk plans
on minor lives
16 3301 Medical Examiner’s Appointment Letter
17 3302 Medical Examiner’s Application Form
18 3318 Medical Examiner’s Diary
19 3441 A & B Policy Register for Annuities
20 3868 A Notice of Assignment enclosed with Provident Fund Policy
21 3868 B Notice of Assignment
22 BM’s recommendation note for appointment of ME
23 Cardiologist, pathologist,radiologist application form
24 Rating Sheet ( revival, ZUS, CUS)
25 Recheck- up of measurements
26 Form No 1 Addendum to proposal under MWP Act cases corresponding to
Clause No 23
27 Form No 1- Addendum to proposal under MWP Act cases corresponding to
A Clause 23 –A
Clause 24
Clause 25
Clause 26
Clause 27
Clause 28
7
Clause 34
Clause 35
Clause 36
8
Clauses required at the time of acceptance of proposals
Insert proposal number at the top in all the cases
Sr Clause Description Form No When Applicable Insertions

No
1 1 Diminishing Lien Clause 3121 When the risk is (a) No of years
of a decreasing for which lien is
nature with operative
increase in age (b) Amount per
thousand S.A.of
the initial lien
(c ) Amount per
thousand by
which the lien
diminishes every
year
2 2 Constant Lien Clause 3122
3 4b Special Clause for female lives 3124 B Applicable in
case of married
female lives
falling under
Category III and
age at entry is 18
years and above
but less than or
equal to 30 years
of age
4 10a Special Minority Clause 3130 A Applicable in

cases where
policies under
risk plans are
issued to minor
lives
5 11 War and Aviation Clause 3131 Applicable to
Aviation
Personnel where
the proposer does
not wish to pay
the aviation and
war risk extra
though
chargeable
6 13 Special War and Aviation 3133 Applicable to all
Clause Ground
Personnel (other
than those having
9
purely non
technical duties)
irrespective of
whether extra
premium is (i)
not chargeable or
(ii) chargeable
and paid
7 14 Change of Occupation Clause 3134 Applicable when
change of
occupation to a
hazardous one is
likely
8 20 Premium Waiver Benefit 3140 Self explanatory
Clause
9 20A Premium Waiver Benefit 3140A Self explanatory
Clause
10 20B Family Benefit Rider Clause 3140 B Self explanatory
11 22 SSS Clause other than LIC 3142
employees
12 23 Special Clause for policies 3143 When Addendum (a)Beneficiary’s
effected under M.W.P.Act No .1 to proposal name, age and
has been relationship
completed (b)Names of the
trustees
13 23 A Special Clause for policies 3143 (A) When Addendum (a)Beneficiary’s

trustees
13 24 Special Clause for policies 3144 When Addendum (a)Beneficiary’s

trustees
14 25 Special Clause for policies 3145 When addendum (a)Beneficiary’s

effected under M.W.P.Act No 3 to proposal name, age and
trustees
( c) Delete
‘survivors of’ if
only two trustees
have been
appointed
10
trustees

trustees
( c) Delete
‘survivors of’ if
only two trustees
have been
appointed
trustees
18 31 Applicable to policies relating 3151 When the Exact percentage

to LIC employees -SSS policies premium is of reduction
deducted from allowed in tabular
salary premium
19 32 Applicable to policies relating 3152 When the Exact percentage
to LIC employees – other than premium is of reduction
SSS policies deducted from allowed in tabular
salary premium
20 34 Special Clauses for policies 3154 Where there is (a) Name, age and
effected under the MWP Act one beneficiary relationship of
and a Bank or beneficiary
Trustee Co.has (b) Name of Bank
been appointed as or Trustee Co.
“Trustees” When
Addendum No 7
to proposal has
been completed
21 35 Special Clauses for policies 3155 Where there are (a) Name, age and
effected under M.W.P two or more relationship of
A ct beneficiaries beneficiary
jointly or (b) Name of Bank
survivor or with or Trustee Co
specified shares
and a Bank or
Trustee Co. has
been appointed as
Trustees- When
11
addendum No 8
& 9 to proposal
have been
completed
22 37 Endorsement by proposer on 3157 When State Bank (a)Name and
the back of policy appointing of India or the Address of the
Bank as Trustees and Bank’s Bank of Baroda proposer
consent has been (b) Name, age
appointed as and relationship
trustees. of beneficiary
(Acceptance by (c ) Name of
the Bank of Trustee Bank
Baroda will be
slightly different)
23 38 Endorsement by proposer on 3158 When the State (a)Name and
the back of policy appointing Bank of India or Address of the
Bank as Trustees and Bank’s the Bank of proposer
consent Baroda has been (b) Name, age
appointed as and relationship
Trustees. of beneficiary
(Acceptance by (c ) Name of
the Bank of Trustee Bank
Baroda will be a
slightly different
form
24 40 Endorsement by proposer on 3194 (a) Name and
the back of Policy appointing Address of the
Central Bank Executor and ---------------- Proposer
Trustee Co.as special Trustees (b) Name, Age
in M.W.P.A cases and Bank’s and relationship
consent. of Beneficiary/ies
(c )Ammount of
acceptance fees
charged by Bank
25 46 Restrictive AB clause Restrictive The reduced
Clause when amount of benefit
accident benefit
is given in part
26 53 Instalment premium inclusive ………… Nil
of Health extra
27 54 Restirctive Clause for PDB & Endorsement Nil
EPDB excluding
disability benefit
28 55 Multiple Nominations Self explanatory
29 56 Minor Nominee with Self explanatory
Appointee
30 59 Endorsement by proposer on 3196 (a) Name and
the back of Policy appointing Address of
12
Canara Bank as Trustees under proposer
M.W.P.A cases (b) Name/s, Age/s
and relationship
of Beneficiary/ies
(c )Rate of
commission
31 65 Special Aviation Clause 3214 Applicable in the

(Amateur Pilots) case of persons
holding private
pilot’s licence or
persons
undergoing
training for
private pilot’s
licence
32 66 Special Aviation Clause 3215 Applicable in
(Civilian Glider Pilots) case of persons
who are engaged
in Civil gliding
ordinary club
member
33 67 Restrictive Clause 3216 Applicable in the
(Paratroopers) case of persons
who have
undergone
training as
paratroopers, but
whose current
duties do not
involve parachute
jumping
34 69 Clause for payment of extra 3218 Applicable in (a) Extra per
premium for the first few years case of proposals thousand per
only from commencement where an extra annum
premium is (b) No. of years
payable on for which extra
account of health premium is
or occupation for payable.
the first few years (c) The reduced
only, from premium payable
commencement and the effective
date
35 70 M.W.P.Act Clauses 3219
36 72 Applicable to single premium 3226 Applicable where
policies where Accident single premium
Benefit is allowed. policy is taken
37 74 Diver’s Clause 3228 Applicable in the
13
case of all divers
38 75 War risks exclusion clause in 3229 Applicable where
case of Submarine personnel Submarine
Personnel do not
desire war risk to
be covered
39 76 CDA subject to satisfactory 3230 Applicable when
medical evidence at vesting the case is
date accepted subject
to satisfactory
medical evidence
at vesting date
40 77 M.W.P.Act Clauses 3219 A
41 78 M.W.P.Act Clauses 3219 B
42 79 M.W.P.Act Clauses 3219 C
43 85 Exclusion Clauses for Accident 3188
Benefit to persons engaged in
hazardous
44 86 Exclusion Clause for sum
assured to persons engaged in
Hazardous occupation but who
do not want to pay occupation
extra
ECR clause
14
15
PROPOSAL / POLICY CLAUSES
Proposal Clause No.1 Form No. 3121
LIFE INSURANCE CORPORATION OF INDIA
Re: Diminishing Lien Clause referred to in the acceptance letter issued in connection with
Proposal No..............................
16
Notwithstanding anything within-mentioned to the contrary, it is hereby declared and
agreed that the sum assured under this Policy will be subject to the Corporation's lien for the
first..................... years of the Policy, the amount of the lien being Rs...............per each Rupees
one thousand sum assured during the first Policy year and thereafter diminishing by
Rs.................................every policy year until the lien is extinguished. In the event of the death
of life assured during the period the Policy is subject to lien, the sum payable by the
Corporation will be reduced by the amount of lien then outstanding. However, should the death
of the life assured occur from any bodily injury resulting solely and directly from accident
caused by outward violent and visible means and within three calendar months of such injury
the said lien shall be inoperative.
p. Sr. Branch Manager

……………………
Proposal Clause No.2 Form No.3122

Re: Constant Lien Clause

agreed that the sum assured under this Policy will be subject to the Corporation's lien of
Rs................per each Rupees one thousand sum assured for the first.................. years. In the
event of the death of life assured during the period the Policy is subject to lien, the sum
payable by the Corporation will be reduced by the amount of lien. However, should the death
of the life assured occur from any bodily injury resulting solely and directly from accident
caused by outward violent and visible means and within three calendar months of such injury
the said lien shall be inoperative.
----------------------------
Proposal Clause No 4(b) Form No.3124 (b)
Branch Office
17
"Notwithstanding anything within mentioned to the contrary, it is hereby declared and
agreed that in the event of death of the life assured occurring as a result of intentional self-
injury, suicide or attempted suicide, insanity, accident other than an accident in a public place
or murder at any time on or after the date on which the risk under this policy has commenced
but before the expiry of three years from the date of this policy, the Corporation's liability shall
be limited to the sum equal to the total amount of premiums (exclusive of extra premiums, if
any) paid under this policy without interest".
Provided that in case the Life Assured shall commit suicide before the expiry of one
year reckoned from the date of this policy, the provisions of the clause under the heading
"Suicide printed on the back of the policy shall apply".
Sr. Branch Manager
………………………
Proposal Clause No. 10(a) Form No. 3130(a)

Special Minority Clause
Re: Proposal Clause to be inserted on the policies where risk commences before majority of
the life assured.
This Policy is issued subject to the undertaking given by the proposer that if the policy
is surrendered or loan, if admissible, is granted under the policy or if the proposer should
receive any moneys under the policy for any reason whatsoever, including Cash option, before
the policy has vested in the life assured as provided in the policy, the proposer shall utilise the
moneys thereby received for the benefit of the life assured or his estate.
Branch_________________
p.Sr.Branch Manager
…………………..
Proposal Clause No.11
Form No.3131
To be inserted in all Policies (under plans other than the Multipurpose plan) where the
proposer does not wish to cover risks of aviation and war by paying the prescribed extra
premium.
____________________________________________________________________________
18
War & Aviation Clause
Policy No........................
agreed than if the death of the life assured occurs :
(a) as a result of or from any cause arising out of his engaging in aviation or air-
travel in any form except as a fare-paying or part-paying or non-paying
passenger for the purposes of transport in an aircraft authorised by the relevant
regulations to carry such passengers and flying between established aerodromes,
having no duties while on board the aircraft or requiring descent there from , or
(b) as a result of or from any cause arising out of war or warlike operations
(whether war be declared or not) or hostilities of any kind while he is employed
in the Air Force or Naval or Military Air Units.
the amount payable under this Policy shall be limited to either -
(i) A sum equal to the total amount of premiums (exclusive of extra premiums)
paid under this Policy, without interest, less any sums paid by the Corporation
in respect of bonuses in cash, portions of sum assured or of Surrender value or
otherwise, or
(ii) The Surrender Value of the Policy,
whichever shall be the greater but shall not exceed in any case the amount which would other-
wise have been payable at death.
p .Sr. Branch Manager
……………………………
Proposal Clause No 13 Form No 3133
Life Insurance Corporation of India

(Established by the life insurance corporation act, 1956)
_________________DIVISION
19
To be inserted in all policies on the lives of Ground Branches personnel (other than
those having purely non-technical duties), irrespective of whether an extra premium is (1) not
chargeable or (2) chargeable and paid.
Special Aviation Clause (Ground Branches Personnel)

agreed that the risk of the life assured engaging in aviation or air travel in the capacity of a
ground technician or that of a fare paying, part-paying or non-paying passenger by an aircraft
authorised by the relevant regulations to carry such passengers and flying between established
aerodromes will be fully covered under the policy. Provided, however, that should the life
assured engage in aviation or air travel in any capacity other than those specified above, he
shall give intimation in writing to the Corporation and the Corporation shall then have the right
to charge such extra premium and/or impose such restriction on the cover provided by the
policy as it may consider appropriate. It is further declared that in the event of the life assured
failing to give such intimation to the Corporation and / or pay the necessary extra premium and
death of the life assured taking place attributable directly or indirectly to his engaging in
aviation in a capacity as described, above, the liability of the Corporation shall be limited to
either –
(a) a sum equal to the total amount of premiums (exclusive of extra premiums) paid under
this policy without interest, less any sums paid by the Corporation in respect of bonuses
in cash, portions of a sum assured or of Surrender Value or otherwise, or
(b) The Surrender Value of the Policy,
whichever shall be greater, but shall not exceed in any case the amount which would other-
wise have been payable at death.
………………………….
Proposal Clause No.14 Form No. 3134
Re: Occupation Endorsement Clause
20
Notwithstanding anything within mentioned to the contrary, it is hereby declared and
agreed that the within written Policy shall be free all restrictions as to travel, residence and
occupation subject to the condition that should there be any change in the occupation at present
followed by the life assured, he shall give intimation thereof to the Corporation and also
furnish to the Corporation such information as the Corporation may then require. The
Corporation shall then be at liberty to charge such extra premium or impose such restrictions
on the policy as it may deem necessary. It is further declared that in the event of the life
assured failing.
(a) to intimate to the Corporation as stated above, or
(b) to furnish such further information as may be required by the Corporation, or
(c) to pay the necessary extra premium required, or
(d) to agree to the restrictions as may be imposed on the policy,
and if the death of the life assured takes place attributable directly or indirectly to such changed
occupation, the amount payable under this policy shall be limited to a sum being either -
(a) The total amount of the premiums (exclusive of extra premiums) paid hereunder
less any sums paid by the Corporation in respect of bonuses in cash, portions of sum assured or
of Surrender Value or otherwise, or
(b) The Surrender Value of the Policy.
whichever shall be the greater but shall not exceed in any case the amount which would
otherwise have been payable at death.
p. Sr. Branch Manager.
………………………….
Proposal clause no 20 Form No 3140

_________________DIVISION
21
Re: Children’s Deferred Assurance and Children Anticipated Assurance – Waiver of premium
clause
In consideration of the payment of an additional installment premium of Rs

.................... (which additional premium is included in the premium shown in the schedule of
the policy), and on condition that there shall be duly paid to the Corporation a similar
additional premium with every installment till the deferred date or the death of the proposer
whichever occurs earlier, it is hereby declared and agreed as follows, notwithstanding anything
within-mentioned to the contrary :-
a) The payment of the premium falling due after the date of death of the proposer and
before the deferred date (but excluding the premium falling due on the deferred date)
shall be waived.
b) The benefit described in a) shall not operate in the event of the death of the proposer by
his own hands whether sane or insane.
c) The additional premium shall not be taken into account in arriving at the amount to be
refunded in the event of death of the within life assured during the deferment period
and in calculating the surrender value of the within policy.
d) The revival of the policy at any time after the first six months from the due date of the
first unpaid premium but not later than the expiry of a period of Five years from the due
date of the said unpaid premium or before the deferred date whichever is earlier shall be
subject to requirement mentioned here-in-below in addition to the requirements
mentioned under the clause “Revival of Discounted or Lapsed Policies”.
Evidence of health and habits of the proposer ( including a Medical Report on his life at
his own expenses from the Corporation’s appointed Medical Examiner, wherever required
by the Corporation) to the satisfaction of the Corporation and of evidence to show that
there has been no adverse change in Personal or Family history or Occupation of the said
proposer
p. Sr /Branch Manager
……………………………..
Clause No.20A Form.No. 3140 A

_________________DIVISION
MONEY BACK CHILDREN’S ASSURANCE – WAIVER OF PREMIUM CLAUSE 20A
22
In consideration of the payment of an additional installment premium of
Rs………….(which additional premium is included in the premium shown in the schedule of
the policy) and on the condition that there shall be duly paid to the corporation a similar
additional premium with every installment till the vesting date or the death of the proposer
within mentioned to the contrary:
a) The payment of the premium falling due after the date of death of the proposer and before
the vesting date shall be waived.
b) The premium waiver benefit as stated in a) above ahs been granted in the basis of the
proposer’s personal statement, declaration and connected documents and in case it is found that
any untrue or incorrect statement is contained therein or material information is withheld, all
claims to the benefit shall cease and determine:
c) The benefit described in a) shall not operate in the event of the death of the proposer by the
own hands whether sane or insane.
d) The additional premium shall not be taken into account in arriving at the amount to be
refunded in the event of death of the within life assured before the date of commencement of
risk and in calculating the surrender value of the policy.
e) The revival of the policy at any time after six months from the due date of the first unpaid
premium but not later than the expiry of a period of Five years from the due date of the said
unpaid premium or before the vesting date which ever is earlier shall be subject to
requirement mentioned here-in-below in addition to clause “Revival of Discontinued
Policies”.
Evidence of health and habits of the proposer (including medical report on his life at his
own expenses from the corporation’s Appointed medical examiner, wherever required by the
corporation) to the satisfaction of the corporation and of evidence to show that there has been
no adverse change in personal or family history or occupation of the said proposer.
p.Sr.Branch Manager
…………………………..
Proposal Clause 20 (B) Clause No 3140 (B)

_________________DIVISION
23
MONEY BACK CHILDREN’S ASSURANCE – FAMILY BENEFIT CLAUSE 20-B
1) Annual premium policy:
In consideration of the payment of an additional instalment premium of

Rs………….(which additional premium is included in the premium shown in the schedule of
the policy) and on the condition that there shall be duly paid to the corporation a similar
additional premium with every installment till the vesting date or the death of the proposer
within mentioned to the contrary:
a) A sum of Rs…………….. will be paid as Family Benefit in case of death of the

proposer before the end of the policy anniversary immediately following the
completion of age 18 years by the within Life Assured .
b) The Family Benefit as stated in a) has been granted on the basis of proposer’s personal
statement, declaration and connected documents and in case it is found that any untrue
or incorrect statement is contained therein or any material information is withheld all
claims to the benefit shall cease and determine ;
c) The benefit described in a) shall not be payable in the event of death of the proposer by
his own hands whether sane or insane;
d) The additional premium shall not be taken into account in arriving at the amount to be
refunded in the event of death of the within life assured before the Date of
Commencement of Risk and in calculating the surrender value of the policy.
e) The revival of the policy at any time after six months from the due date of the first
unpaid premium but not later than the expiry of a period of Five years from the due
date of the said unpaid premium or before the vesting date which ever is earlier shall be
subject to requirement mentioned here-in-below in addition to the requirements
mentioned under the clause “Revival of discountinued Policies”
Evidence of health and habits of the proposer ( including medical report on his life at
his own expenses from the Corporation’s appointed Medical Examiner, wherever required by
the Corporation) to the satisfaction of the Corporation and of evidence to show that there has
been no adverse change in personal or Family History or occupation of the said proposer.
p.Sr./Branch Manager
…………………………..

Annexure-I1(A)
Re: Clause for payment of monthly premium under Salary Saving Scheme
24
POLICY No.....................................
1) This Policy having been issued under the Corporation's Salary Savings Scheme, it is
hereby declared that the instalment premium shall be payable at the rate shown in the
Schedule of the Policy so long only as the Life Assured / Proposer continuous to be an
employee of his/her present employer whose name is stated in that Proposal, and the
premiums are collected by the said employer out of the salary of the Life Assured /
Proposer as authorized by him/her and remitted to the Corporation without any charge.
It shall be the responsibility of the Life Assured / Proposer to insure that the installment
premium is deducted from his/her salary and remitted to the Corporation or failing that
premium is paid directly to the Corporation within days of grace at increased rates.
2) In the event of the Life Assured/Proposer leaving the employment of the said employer
or the premiums ceasing to be so collected or the collected premiums not remitted to
the Corporation, the Life Assured/Proposer must intimate the fact to the Corporation
and in the event of the Salary Saving Scheme being withdrawn from the said employer,
the Corporation shall intimate the fact to the Life Assured/Proposer and all premiums
falling due on and after the date of his/her leaving the employment of the said employer
or cessation of collection of the premiums or remittance thereof in the manner as
aforesaid or withdrawal of the Salary Savings Scheme, as the case may be, shall stand
increased by the imposition of the additional charge for monthly payment that has been
waived under the Salary Savings Scheme at five per cent of the premium exclusive of
any premium charged for Accident Benefit and any other extra premium charged.
3) During the period in which the premium is remitted to the Corporation through the
employer, the instalment premium will be deemed to fall due on the 20th day of each
month instead of the due date mentioned in the said policy.
4) It is also declared that this policy shall stand lapsed if the due premium is not received
by the Corporation within 15 days of the due date as mentioned above and the Life
Assured/Proposer, being primarily responsible to keep the policy inforce, shall remit
the defaulted premium dues together with the additional charges applicable for monthly
payment and with interest, if any at the prevailing rates charged by the Corporation for
the belated payment of premiums. In the event of the premium dues not remitted to the
Corporation either by the employer or by the Life Assured/Proposer and the policy
becoming lapsed, the liability of the Corporation under the
25
within-mentioned policy will be restricted to the extent of the premiums actually
received by it and to the provisions of the conditions and privileges governing the
policy and no further relief for any claim shall lie with the Corporation.
I HEREBY GIVE MY CONSENT FOR THE IMPOSITION OF THE ABOVE CLAUSE NO
22 ON THE POLICY.
Signature of the policyholder Signature of the witness
…………………………….
Annexure – I (A)

( Established by the Life Insurance Act,1956 )
_______________ DIVISION
26
I, _____________________________ (Name), Son/Daughter of
___________________________ (Name) am submitting a proposal dated __________ for life
insurance with Life Insurance Corporation of India (hereinafter called the “Corporation”) and I
request that the policy for this proposal be issued by the Corporation under Salary Savings
Scheme (hereinafter called the “Scheme”) maintained with my Employer
_____________________________ (hereinafter called the “Employer”) on the under
mentioned terms and conditions.
1. The instalment premium as mentioned on the schedule of the policy to be issued

shall be payable on the due date during the term of the policy or earlier death so
long as I continue to be the employee of the present employer. If the premium is not
paid during the days of grace, the policy will lapse.
2. I agree that I shall be entirely responsible for keeping the policy to be issued by the
corporation in force by regular payment of premiums on due dates, but since I am an
employee of _______________________ where Salary Saving Scheme of the
corporation is in operation, I hereby authorize my employer __________________
to make monthly deduction of premium amount from my salary and remit the same
to the corporation acting as representative on my behalf.
3-.The premiums including arrears of premiums with interest, if any, as may be
intimated by the Corporation to the employer, be deducted from my salary or any
other compensation that may be payable to me by the employer for every due month
regularly and remitted to the Corporation within the stipulated time up to the month
and the year of the last instalment as may be indicated by the Corporation or till I
give a specific notice in writing to the Corporation and to the employer or till I leave
the services of the employer.
4- It is further declared and agreed that while deducting the premium from my salary
and remitting it to the Corporation, the employer is acting on my behalf and in no
way the employer is representing the Corporation.
5- As stated, I shall be entirely responsible for keeping the policy to be issued by the
Corporation in force by ensuring the payment of premium to the Corporation within
the stipulated time. In the event of the non payment of the premium to the
Corporation by the employer for whatever reason, it shall be my responsibility to
make the payment of premiums directly to the Corporation together with the
additional charges as applicable for monthly payment of premium and with interest, if
any, to keep the policy in force.
6- I agree that in the event of the said policy becoming lapsed on account of the non-
payment of the premiums to the Corporation within the stipulated time for whatever
reasons, the liability of the Corporation will be limited to the extent of the premiums
actual received by it and the Corporation shall not be responsible for any claim
beyond this liability as accrued to the said policy at the time of its lapsation.
7- I also agree that the authorisation for the deduction of premiums from my salary and
it’s remittance to the Corporation will not be withdrawn by me until the premiums
have been paid for a minimum period of three years from the date of commencement
of this procedure.
8- I agree that in the event of the cessation of the said policy from the scheme on
account of my leaving the employment of the employer or the scheme being
withdrawn from the employer, the premium shall stand increased by the imposition
of the additional charges for the monthly payment that has been waived under the
27
scheme at he rate of 5% of the premium exclusive of any premium charged for the
double accident benefit or other extra premiums.
9- I undertake to inform the Corporation from time to time any changes in my address
for communication
10- During the period in which the said policy is under the scheme, the instalment
premium will be deemed to fall due on 20th. Day of each month instead of the due
date mentioned in the said policy.
Dated at---------------on the------------day of----- (Month)----------(Year)
SIGNATURE OF WITNESS: SIGNATURE OF THE POLICYHOLDER

NAME------------------------
ADDRESS---------------------
--------------------------------
…………………………..
Clause No. 23 Form No. 3143

(Corresponding to Addendum No.1)
28
Form of Endorsement for use in case where there is only one Beneficiary and more than one
Special Trustees have been appointed jointly or the survivor of them.
__________________________________________________________________________
This Policy is issued under the provisions of the Married Women's Property Act, 1874,
(Place & Date)
for the benefit of the Proposer's __________________________________________________
aged
(Relationship and name of the Beneficiary)
_________ years and (1)
___________________________________________________________
(Name of the Special Trustee)
and (2) ____________________________________________________________________
jointly or the survivor of them have been appointed as Special Trustees under the provisions of
Section 6 of the said Act to receive the Policy moneys and hold the aforesaid Trust with power
and authority to the said Trustees to obtain any loan or loans on the security of the Policy from
the Life Insurance Corporation of India for the benefit of the aforesaid provided he/she is major
and competent to contract and with power to the Proposer (a) to appoint by a Deed a new
Trustee or new Trustees in case either of the abovementioned Trustees dies or declines or is
disqualified to act under the law or becomes incapable to act or cannot act for any reason
whatsoever and (b) to revoke by a Deed the appointment of the above named Trustees and
appoint others in their stead.
For THE LIFE INSURANCE CORPORATION OF INDIA
p. Sr/Branch Manager
…………………………….
Clause No. 23(A) Form No. 3143(A)

(Corresponding to Addendum No.1A)
29
Form of Endorsement for use in case where there is only one Beneficiary (Wife, Son or
Daughter) and one person has been appointed as Special Trustee
__________________________________________________________________________
This Policy is issued under the provisions of the Married Women's Property Act, 1874, (Place
& Date)
for the benefit of the Proposer's__________________________________________________

aged _____________years and ___________________________________________________

(Full name of the Special Trustee)
has been appointed as Special Trustees under the provisions of Section 6 of the said Act to
receive the Policy moneys and hold the same upon the aforesaid Trust with power and
authority to the said Special Trustee to obtain any loan or loans on the security of the Policy
from the Life Insurance Corporation of India for the benefit of the aforesaid Beneficiary
provided he/she is major and competent to contract and with power to the Proposer (a) to
appoint by a Deed a new Special Trustee or Trustees in case the above named Special Trustee
dies or declines or is disqualified to act under the law or becomes incapable to act or cannot act
for any reason whatsoever and (b) to revoke by a Deed the appointment of the above named
Special Trustee and appoint other in his/her stead.
……………………………
Clause No.24 Form No. 3144

30
Form of Endorsement for use in case where there is only one Beneficiary and a Special Trustee
failing him another Special Trustee has been appointed
__________________________________________________________________________
& Date)
for the benefit of the Proposer's__________________________________________________

aged _____________years and ___________________________________________________

failing him/her or if he/she dies, declines or becomes incapable to act or is disqualified under
the Law or cannot act due to any reason whatsoever
(Name of the alternate special trustee)
has been appointed as Special Trustees under the provisions of Section 6 of the said Act to
authority to the said Trustee to obtain any loan or loans on the security of the Policy from the
Life Insurance Corporation of India for the benefit of the aforesaid Beneficiary provided he/she
is major and competent to contract and with power to the Proposer (a) to appoint by a Deed a
new trustee or new trustees in case the above named Trustees dies or declines or is disqualified
under the law or becomes incapable to act or cannot act for any reason whatsoever and (b) to
revoke by a Deed the appointment of the above named Trustee and appoint others in his/her
stead.
………………………..


Form of Endorsement for use in case where there are two or more
31
Beneficiaries jointly or survivor and more than one Special Trustee,
jointly or survivor, have been appointed.
__________________________________________________________________________
& Date)
for the benefit of the Proposer's
(1) __________________* ________________________aged ___________________years,

(2) __________________* ________________________aged ___________________years,
(3) __________________* ________________________aged _________________ years and
(4) __________________*_________________________aged___________________years,
jointly or the survivors or survivor of them, and
__________________@________________________________________________________
__________________@
_______________________________________________________and
jointly or the survivors or survivor of them have been appointed as special Trustees under the
provisions of Section 6 of the said act to receive the Policy moneys and hold the same upon the
aforesaid Trust with power and authority to the said Trustees to obtain any loan or loans on the
security of the Policy from the Life Insurance Corporation of India for the benefit of the
aforesaid Beneficiaries provided they are all major and competent to contract and all of one
mind and with power to the Proposer(a) to appoint by a Deed a new Trustee or new Trustees
in case either of the above named Trustees dies or declines or is disqualified under the law or
becomes incapable to act or cannot act for any reason whatsoever and (b) to revoke by a Deed
the appointment of the above named Trustees and appoint others in their stead.
* State relationship and names of Beneficiaries.

@ State Names of Special Trustees.
………………………..
Clause No.26) Form No. 3146
32
Form of Endorsement for use in case where there is two or more beneficiaries jointly or
survivor a Special Trustee failing him another Special Trustee or single Special Trustee has
been appointed).
__________________________________________________________________________
& Date)
(1) __________________* ________________________aged ___________________years,

(2) __________________* ________________________aged ___________________years,
(3) __________________* ________________________aged __________________years and
(4) __________________*_________________________aged___________________years,
jointly or the survivors or survivor of them, and
_______________@___________________________________________________________
** or failing him/her or if he/she dies or declines or becomes incapable to act or is disqualified
under the law or cannot act for any reason whatsoever,
________________@__________________________________________________________
have been appointed as a Special Trustee under the provisions of Section 6 of the said Act to
receive the Policy moneys and hold the same upon the aforesaid Trust, with power and
authority to the said Trustee to obtain any loan or loans on the security of the Policy from the
Life Insurance Corporation of India for the benefit of the aforesaid Beneficiaries provided they
are all major and competent to contract and all of one mind and with power to the Proposer (a)
to appoint by a Deed a new Trustee or new Trustees in case either of the above named Trustees
dies or declines or becomes incapable to act or is disqualified under the law or cannot act for
any reason whatsoever and (b) to revoke by a Deed the appointment of the above named
Trustees and appoint others in their stead.
@ State Names of Special Trustees.
** Delete if not applicable.
…………………………
(Clause No.27)
Form No. 3147
33
Form of Endorsement for use in case where two or more Beneficiaries
with specified shares have been appointed and more than one Special
Trustee, jointly or survivor, have been appointed.
__________________________________________________________________________
& Date)
(1) __________________* ________________________aged ___________________years,

(2) __________________* ________________________aged ___________________years,
(3) __________________* _______________________ aged _________________years and
(4) __________________*_________________________aged_________________years,
in the shares of _____________________________________________________respectively
and (1) ______* * ________________________________________________________
and(2)_______* * _________________________________________________________
jointly or the survivors or survivor of them have been appointed as Special Trustees under the
provisions of Section 6 of the said Act to receive the Policy moneys and hold the same upon
the aforesaid Trust with power and authority to the said Trustees to obtain any loan or loans on
the security of the Policy from the Life Insurance Corporation of India for the benefit of the
aforesaid Beneficiaries provided they are all major and competent to contract and all of one
mind and with power to the Proposer (a) to appoint by a Deed a new Trustee or new Trustees
in case either of the above named Trustees dies or declines or is disqualified under the law or
becomes incapable to act or cannot act for any reason whatsoever and (b) to revoke by a Deed
the appointment of the above named Trustees and appoint others in their stead.
* * State Names of Special Trustees
……………………………
(Clause No.28) Form No. 3148

34
Form of Endorsement for use in case where two or more Beneficiaries, with specified shares
have been appointed and a Special Trustee and an alternate Special Trustee has been appointed
______________________________________________________________________
______This Policy is issued under the provisions of the Married Women's Property Act, 1874,
(Place & Date)
(1) __________________* ________________________aged ___________________years,

(2) __________________* ________________________aged ___________________years,
(3) __________________* ________________________aged ___________________years
and
(4) __________________*_________________________aged___________________years,
in the shares of ____________________________respectively, and ____ *___*

____________ ____________________or failing him/her or if he/she dies or declines or
becomes incapable to act or is disqualified under the law or cannot act for any reason
whatsoever.
______________*___ * ________________________________________________________
have been appointed as Special Trustees under the provisions of Section 6 of the said Act to
authority to the said Trustees to obtain any loan or loans on the security of the Policy from the
Life Insurance Corporation of India for the benefit of the aforesaid Beneficiaries provided they
are all major and competent to contract and all of one mind and with power to the Proposer (a)
to appoint a new Trustee or new Trustees in case either of the above named Trustees dies or
becomes incapable to act or is disqualified under the law by a Deed or cannot act for any
reason whatsoever and (b) to revoke by a Deed the appointment of the above named Trustee
and appoint others in their stead.
…………………………..
35
Re: Clause for payment of monthly premium under the Corporation Employee's Insurance
Scheme by deduction from Salary.
POLICY No.....................................
The Life Assured being an employee of the Life Insurance Corporation of India
(hereinafter referred to as "Corporation"), and the Corporation's Salary Savings Scheme
having been made applicable to the employees of the aforesaid Corporation, it is hereby
declared and agreed that the instalment premium shown in the Schedule under the policy shall
be applicable so long as the Life Assured continues to be an employee of the said Corporation
and the premiums continue to be deducted from his/her salary payable by the said Corporation.
In the event of the life assured discontinuing payment of premium by deduction from his/her
salary while continuing to be in the service of the said Corporation or in the event of stoppage
of deduction of premium from his/her salary as a result of his/her retirement from the
Corporation he/she shall intimate that fact to the Corporation and the instalment premiums
falling due after such discontinuance shall stand increased by imposition of additional charge
for monthly payment that has been waived under the Salary Savings Scheme at five percent of
the premiums exclusive of any premiums charged for accident benefit and any other extra
premium charged. It is further declared that in the event of the Life Assured leaving the
services of the said Corporation otherwise than by retirement, he/she shall intimate that fact to
the Corporation and the instalment premium falling due on and after his/her so leaving the said
service shall be increased as stated herein above and further by withdrawal of the reduction that
has been allowed under the Corporation Employees' Insurance Scheme at the rate of
............................of the tabular premium.
During the period in which the premium is deducted form the salary every month by
the Corporation, the instalment premium will be deemed to fall due on the 20th day of each
month instead of the due date within-mentioned.
p. Sr./Branch Manager
…………………………
36
Policy Clause No.32 Form No.3152

Re : Clause for payment of premium, under the Corporation Employees’ Insurance Scheme
otherwise than by deduction from Salary
POLICY NO......................
agreed that in the event of the Life Assured leaving the service of the Life Insurance
Corporation of India otherwise than by retirement, he/she shall intimate that fact to the
Corporation and the
instalment premiums falling due on and after his/her so leaving the said service shall be
increased by withdrawal of the reduction that has been allowed under the Corporation
Employee's. Insurance Scheme at the rate of ...........................of the tabular premium.
p. Sr. / Branch Manager
………………………..
Clause No.34) Form No. 3154

Form of Endorsement for use in case where there is only one Beneficiary and a Bank or
Trustee Co. has been appointed as a Special Trustee.
__________________________________________________________________________
The within Policy is issued under the provisions of the Married Women's
(Place & Date) Property Act, 1874, for the benefit of the Proposer's
_______________________________
aged ________years and (2) _________________________________________________
(Name of the Bank or Trustee Company)
receive the Policy moneys and hold the same upon the aforesaid Trust, with power and
authority to the said Trustees to obtain any loan or loans from the Life Insurance Corporation
of India for the benefit of the aforesaid Beneficiary he/she is major and competent to contract
and with power to the Proposer (a) to appoint by a Deed a new Trustee or new Trustees in case
the above named Trustee declines or becomes incapable to act or is disqualified under the law
or cannot act for any reason whatsoever and (b) to revoke by a Deed the appointment of the
above named Trustee and appoint others in their stead.
p.Sr/Branch Manager
37
(Corresponding to Addendum No.8 & 9)
Form of Endorsement for use in case where there are two or more
Beneficiaries jointly or survivor or with specified shares and a
Bank or a Trustee Company has been appointed as a Special Trustee
__________________________________________________________________________
The within Policy is issued under the provisions of the Married Women's Property
(Place & Date)
Act, 1874, for the benefit of the Proposer's
(1) _______________*_________________________aged___________years,
(2) _______________* ________________________aged ___________years and
(3) _______________*_________________________aged___________years,
jointly or the survivors or survivor of them in the shares of _____________________________

respectively and
__________________________________________________________________
(Name of the Bank or Trustee Company)
authority to the said Trustees to obtain any loan or loans from the Life Insurance Corporation
of India for the benefit of the aforesaid Beneficiaries provided they are all major and competent
to contract and all of one mind and with power to the Proposer (a) to appoint by a Deed a new
Trustee or new Trustees in case the above named Trustee declines or becomes incapable to act
or is disqualified under the law or cannot act for any reason whatsoever and (b) to revoke by a
Deed the appointment of the above named Trustee and appoint others in their stead.
p.Sr/Branch Manager
State relationship and names of Beneficiaries. Note: Remove the words "from the Life
Insurance Corporation of India where State Bank of India
or United Commercial Bank has been appointed as Special Trustee.
…………………………….
38
(Corresponding to Addendum No.7, 8 & 9)

Form of Endorsement for use in case where Bank of Baroda
or the State Bank of India has been appointed as a Special Trustee
__________________________________________________________________________
I, _________________________________________________of________________________
(Name of the proposer)
____________________________________________________________________________
Address of the Proposer)
the Life Assured under the within Policy of assurance expressed on the face thereof to be for
the benefit of my
(Relationship and Name/s of beneficiary/ies)

aged ____________years under Section 6 of the Married Women's Property Act, 1874 DO
HEREBY APPOINT The Bank of Baroda/State Bank of India (hereunder referred to as "The
Bank") as Special Trustee to receive from the Life Insurance Corporation of India all moneys
due under the said Policy when the same becomes payable under the terms thereof and to hold
the same upon the Trusts, powers and provisions expressed in the said Policy AND I HEREBY
DECLARE that the Bank in the discharge of its duties and in the exercise of all the powers as
such Trustees as aforesaid may act by its proper officer or officers appointed in that behalf and
may employ solicitors or other agents to transact any business required to be done in the
premises (including the receipt and payment of money) and may (without being liable to
account for any profit thereby made) retain as Bankers on current account or deposit account or
advance all moneys necessary or convenient to be retained or advanced as aforesaid in
connection with Trusts premises and shall be entitled to be allowed and paid such charges,
expenses, interest and commission as it charges its customers in the ordinary course of its
business and the Bank shall also be entitled to remuneration for its services as Trustee in
accordance with its scale of fees now in force.
Dated at ___________ this ____________day of _______________20______________
SIGNEDAND DELIVERED by the above named in the presence of :

Full Name :
Signature :
Occupation :
Address :
Signature of Life Assured
WE, BANK OF BARODA, AGREE to act as "TRUSTEE" as abovementioned.

Dated at ____________this__________day of ____________20____________________
SIGNED AND DELIVERED by Bank of Baroda by SHRI
______________________________ of the Bank authorised in this behalf.
(Full Name & Designation)
Signature…………………………… NOTE : Where the State Bank of India are the Trustee,
the Endorsement of acceptance of the Trust will be made by them.
39
(Corresponding to Addendum No.7, 8 & 9)
Form of Endorsement for use in case where Bank of India
has been appointed as a Special Trustee
____________________________________________________________________________
WHEREAS I, _____________________________________________________________of
(Name of the Proposer)
____________________________________________________________________________
__
(Address of the Proposer)
a married man, have effected a policy of insurance No._______________on my life with the Life
Insurance Corporation of India for the sum of Rs.___________expressed on the face of the policy to be
for the benefit of my (i) ______________________________________________________
and WHEREAS under Section 6 of the Married Women's Property Act, 1874, the said Policy shall ensure
and be deemed to be a trust for the abovementioned beneficiary/beneficiaries AND WHEREAS the Bank
of India having upon my request agreed to act as Special Trustee of such trust, as is evidenced by their
endorsing their acceptance and concurrence at foot hereof, I am desirous of appointing them as Special
Trustee of the said trust upon the terms hereinafter mentioned.
NOW THESE PRESENTS WITNESS that I, _________________________________________
do hereby appoint the Bank of India, the Special Trustee of the said trust to receive from the Life
Insurance Corporation of India the amount of the said Policy and to hold such amount upon trust first to
reimburse unto themselves for their acceptance fees the sum of Rs._________**________ * (or
Rs.______________________according as the amount of the policy moneys in Rs._______ or
Rs._______**______) and next to pay the whole of the balance in their hands to my
______________________________________________________________________________
*** Provided that in the event of the amount payable under the policy being paid to the Trustee otherwise
than in one lump sum, the Trustee shall be entitled to recover from the first instalment received and to the
extent of any deficiency from the subsequent instalments the whole of its above acceptance fees and shall
also be entitled to make an additional charge of 50 paise for every Rs.100/- or part thereof and deduct out
of pocket expenses, if any, on and from every subsequent instalment until the whole of the amount
payable under the policy shall be paid in full.
Dated at_________________ this _____________day of ______________20________
WITNESS :
Signature :
Occupation :
Address : Signature of the Life Assured
The Bank of India, doth hereby accept the trust hereinabove contained and agree to act accordingly.
In witness whereof Shri ______ the duly constituted attorney of the Bank of India, has for and on
behalf of the Bank hereunto set his hand this _______day of ______19______ SIGNED AND
DELIVERED for and on behalf of
The Bank of India, by Shri ______________________Signature ________________________ is duly
constitued attorney in the presence of __________Signature ________________________
40
* Use this clause in case where the policy contains double indemnity benefit for death by
accident.**State the amount of the acceptance fees calculated on the basis of the appropriate
scales given at the end of the chapter
*** To be used where the policy moneys are payable otherwise than in lump sum
41
Clause No 40 Form No 3194

(Corresponding to Addendum Nos 7, 8 or 9)
Form of Endorsement for use in case where Central Bank Executor & Trustee Co
Ltd. has been appointed as a Special Trustee
___________________________________________________________________________
Address: Signature of Life
Assured.

___________________________________________________________________________
a married man, have effected a policy of insurance on my life with the Life Insurance
Corporation of India numbered……………for the sum of Rs ……….expressed on the face of
the policy to be for the benefit of
my……………………………………………………………………………………………..
……………………………………………………………………………………………………
………
and WHEREAS under Section 6 of the Married Women’s Property Act, 1874, the said Policy
shall enure and be deemed to be a trust for the above named beneficiary/ beneficiaries AND
WHEREAS the Central Bank Executor & Trustee Co. Ltd; having upon my request agreed to
act as Special Trustee of such trust, as is evidenced by their endorsing their acceptance and
concurrence at foot hereof, I am desirous of appointing them as Trustees of the said trust upon
the terms hereinafter mentioned,
NOW THESE PRESENTS WITNESS that
I,_________________________________________
(Name of the (Proposer)
do appoint hereby the Central Bnak Executor & Trustee Co. Ltd; the Special Trustees of the
said trust to receive from the Life Insurance Corporation of India the amount of the said Policy
and to hold such amount upon trust first to reimburse unto themselves all costs, charges and
expenses incurred if any, in realizing the amounts, next to pay the whole of the balance in their
hands to my said ________________________________ in accordance with the trust
declared within policy. (Relationship and name of the Beneficiary)
The company is hereby authorized to charge its commission at the rate of
***_____________paise per cent on the claim amount, subject to a minimum of
Rs***_______________________
*Provided that in the event of the amount payable under the policy being paid to the Special
Trustee otherwise than in one lump sum, the Special Trustee shall be entitled to recover from
the first instalment received and to the extent of any deficiency from the subsequent
instalments,the whole of its above acceptance fees, and shall also be entitled to make an
additional charge of 50 paise for every Rs 100/- or part thereof and deduct out of pocket
expenses, if any, on and from any subsequent instalment until the whole of the amount payable
under the policy shall be paid in full.
42
Dated at__________________this ______________day of _______________20
WITNESS:
Signature:
Occupation
The Central Bank Executor & Trustee Co Ltd; doth hereby accept the trust hereinabove
contained and agree to act accordingly.
***State the amount of commission calculated on the basis of the appropriate scales given at
the end of this chapter
* To be used where the policy moneys are payable otherwise than in one lump sum.
……………………………….
43
Wordings of Proposal Clauses 46 , 53 , 54, 55, 56
Clause 46 – Endorsement to be place in the policy document for reducing the amount of accident benefit
46 Notwithstanding anything within-mentioned to the contrary, it is hereby declared and agreed that
the liability of the Corporation under the policy conditions headed "Accident Benefit" shall be
limited to Rs. …………………………………………………………………………..
p. Sr/ Br. Manager
Clause 53- Endorsement to be stamped in the policy document whenever instalment premium includes
any extra
53 The instalment premium stated in this policy is inclusive of an extra premium.
Clause 54- Endorsement to be stamped in the policy document where disability benefit is to be excluded
54 “Disability Benefit” privilege is not applicable to this policy.
Clause 55- Endorsement to be stamped in the policy document where there are more than one nominee.
55 Names of the nominees under section 39 of the Insurance Act, 1938.
Clause 56- Endorsement to be stamped in the policy document where name of appointee has to be
inserted in case of a minor nominee.
56 Names of the person appointed to receive policy moneys during the minority the nominee
or nominees in accordance with Section 39 of the Insurance Act, 1938.
44
Clause No. 59 Form No 3196
(Corresponding to Addendum Nos. 7, 8 or 9)
Form of Endorsement for use in case where Canara Bank has been appointed as a Special Trustee
------------------------------------------------------------------------------------------------------------------------------
WHEREAS I, ____________________________________________________________________of
_______________________________________________________________________________
(Address of the proposer)

a married man, have effected a policy of insurance on my life with Life Insurance Corporation of India,
numbered ____________ for the sum of Rs._________________________ expressed on the face of the
policy to be for the benefit of my _________________________________________________________
____________________________________________________________________________________
and WHEREAS under Section 6 of the Married Women's Property Act 1874, the said Policy shall ensure
and be deemed to be a trust for the above named beneficiary/beneficiaries AND WHEREAS the Canara
Bank having upon my request agreed to act as Special Trustees of such trust, as is evidenced by their
endorsing their acceptance and concurrence at foot hereof, I am desirous of appointing them as Trustees
of the said trust upon the terms hereinafter mentioned.
NOW THESE PRESENTS WITNESS THAT I, _____________________________________________
____________________________________________________________________________________
do hereby appoint the Canara Bank (hereinafter referred to as `THE BANK') the Special Trustees of the
said trust to receive from the Life Insurance Corporation of India the amount of the said Policy when the
same becomes payable and to hold the same upon trust first to reimburse unto themselves all costs,
charges and expenses incurred if any, in realising the amounts, next to pay the whole of the balance in
their hands to my said *_________________________________________________________________
in accordance with the trust declared in the within policy.
AND I HEREBY DECLARE THAT the Bank in the discharge of its duties and in the exercise of all its
powers may act by its Officer or Officers appointed by the Bank in that behalf and may employ solicitors
or any professional advisers and agents to transact all or any business of whatsoever nature required to be
done in the premises of the said trust and shall be entitled to be allowed and be paid out of trust all
charges and expenses so incurred and may (without being liable to account to any profit thereby made)
act as Banker and retain on Current or Savings account or deposit receipt or advance all moneys
necessary or convenient to be retained or advanced in connection with the trust premises and shall be
entitled to be allowed and paid such charges, expenses, interest and commission as it charges its
customers in the ordinary course of its business. The Bank is hereby authorised to charge its commission
at the rate of *____________per cent on the claim amount subject to a minimum of Rs. *___________
and such amount of the commission shall be a first charge on the premises of the said trust.
Dated at ____________________this ____________________day of _____________20
__________________
(Signature of the Life Assured)
45
Witness:
Signature:
Full Name
And Address:
WE, CANARA BANK, do hereby accept the trusts hereinabove contained and agree to accordingly.
In witness whereof Shri________________the duly constituted attorney of the Canara Bank has for and
on behalf of the Bank hereunto set his hand this ___________day of 20__________ at
________________
Signed and delivered for and

On behalf of the Canara Bank
By_____________________ ____________________________
Its duly constituted attorney Signature of the attorney and the

In the presence of ___________________ seal of the Bank
____________________________
Signature of the witness
*State the amount calculated on the basis of appropriate scales given at the end of this chapter.
46
Proposal Clause 65 Form No 3214

To be inserted in policies on the lives of persons holding Private Pilot’s License or Persons
undergoing training for Private Pilot’s License
Special Aviation Clause (Amateur Pilots)
Notwithstanding anything within mentioned to the contrary, it is hereby declared and

agreed that in the event of the life assured deciding to undergo training for commercial pilot’s
license he shall inform the Corporation and pay such additional premium as the Corporation
may determine failing which in the event of death of the life assured occurring while he is
undergoing such training or subsequent to the completion of such training.
(a) as a result of or from any cause arising out of his engaging in aviation or arrival in any form
except as a fare paying or part-paying or non-paying passenger for the purposes of transport
in an aircraft authorized by the relevant regulations to carry such passengers and flying
between established aerodromes, having no duties while on board the aircraft or requiring
descent there from, OR
(b) as a result of or from any cause arising out of war or warlike operations (whether war be
declared or not) or hostilities of any kind while he is employed in the Air Force or Naval or
Military Air Units,
the amount payable under this Policy shall be limited to either……
(i) A sum equal to the total amount of premiums (exclusive of extra premiums) paid under
this Policy, without interest, less any sums paid by the Corporation in respect of bonuses
in cash, portions of sum assured or of Surrender Value or otherwise, or
(ii) The Surrender Value of the Policy,
Whichever shall be the greater, but shall not exceed in any case the amount which would
p. Sr./ Branch Manager
47
To be inserted in policies on the lives of Civilian Glider Pilots
Special Aviation Clause (Civilian Glider Pilots)

Notwithstanding anything within mentioned to the contrary,it is hereby declared and agreed
that if the death of the life assured occurs directly or indirectly from travel or flight in or
descent from any powered aircraft while,
(1) the life assured is a pilot or a member of the crew of such aircraft, or
(2) the aircraft is being operated for aviation training, or
(3) the life assured has any duties aboard such aircraft, or duties requiring descent there
from or
(4) such aircraft is being flown for test or experimental purposes,
The amount payable under this policy shall be limited to either _
(i) A sum equal to the total amount of premiums (exclusive of extra premiums) paid
under this policy, without interest, less any sums paid by the Corporation in respect
of bonuses in cash, portions of sum
(ii) The Surrender Value of the policy,
Whichever shall be greater, but shall not exceed in any case the amount which
would otherwise have been payable at death.

To be inserted in policies on the lives of those who have undergone training as paratroopers but
whose current duties do not involve Parachute jumping.
48
Restrictive Clause (Paratroopers)
Notwithstanding anything within mentioned to the contrary it is hereby declared and agreed that
should the life assured undergo or be called upon to undergo training as a paratrooper or
undertake or be called upon to undertake duties as a paratrooper, he shall give intimation in
writing to the Corporation that he is undergoing such training or has undertaken such duties and
shall pay such extra premium as the Corporation would require him to pay. It is further declared
that in the event of the life assured failing to give such intimation to the Corporation and / or to
pay the necessary extra premium and death of the life assured taking place attributable directly or
indirectly to his training as a paratrooper or duties as a paratrooper, the amount payable under this
policy shall be limited to a sum being either:-
(a) A sum equal to the total amount of premiums (exclusive of extra premiums) paid under this
policy, without interest, less any sums paid by the Corporation in respect of bonuses in cash,
portion of sum assured or of Surrender Value or otherwise, or
(b) The Surrender Value of the Policy,
Whichever shall be the greater but shall not exceed in any case the amount which would
otherwise have been payable at death and further that in the event of permanent disability
occurring as a result of or from any cause arising out of the life assured’s training as a paratrooper
or duties as a paratrooper the Disability Benefit will not be available under the policy.
p.Sr / Branch Manager
Re: Clause for payment of extra premium for the first few years only from commencement
The instalment premium stated in the within policy is inclusive of an extra premium of Rs
……..per thousand per annum payable for a period of ………years from the
49
commencement of the policy. In consequence, the instalment premium under the within
mentioned policy shall stand reduced to Rs…………as from………….
p. Sr/ Branch Manager

(Corresponding To Addendum Nos 7,8 or 9)

Form of Endorsement for use in case where Western India Trustee & Executor Co Ltd. Are
Special Trustees and sum assured is payable (i) in lump sum and (ii) otherwise than in lump
sum
WHEREAS I------------------------------------------------------------------------------------------
50
Corporation of India numbered----------------for the sum of Rs ------------expressed on the
face of the policy to be for the benefit of my -------------------------------------------------
and WHEREAS under Section 6 of the Married Women’s Property Act, 1874, the said
Policy shall enure and be deemed to be a trust for the above mentioned beneficiary /
beneficiaries AND WHEREAS the WESTERN INDIA TRUSTEE and EXECUTOR CO
LTD,SATARA having upon my request agreed to act as Special Trustees of such trust, as is
evidenced by their endorsing their acceptance and concurrence at foot hereof, I am desirous
of appointing them as Special Trustees of the said trust up on the terms hereinafter
mentioned.
NOW THESE PRESENTS WITNESS that I,--------------------------------------------
do hereby appoint THE WESTERN INDIA TRUSTEE and EXECUTOR CO
LTD,SATARA , the Special Trustees of the said trust to receive from the Life Insurance
Corporation of India the amount of the said policy and to hold such amount upon trust first
to reimburse unto themselves for their acceptance fees the sum of Rs.*------------@ or
(Rs.*------------according as the amount of the policy moneys is Rs.-----------or Rs.*----------
) and next to pay the whole of the balance in their hands to
my__________________________________________________
**PROVIDED that in the event of the amount payable under the policy being paid to the
Special Trustee otherwise than in one lump sum, the Special Trustee shall be entitled to
recover from the first instalment received and to the extent of any deficiency from the
subsequent instalments received the whole of its above acceptance fees and shall also be
entitled to make an additional charge of 50 paise for every Rs 100/- or part thereof and
deduct out of pocket expenses, if any, on and from every subsequent instalment until the
whole of the amount payable under the policy shall be paid in full.
Dated at_______________this _________day of _________________20
WITNESS:
Signature:
Occupation:
Address: Signature of the Life Assured.
WE, THE WESTERN INDIA TRUSTEE and EXECUTOR CO LTD, SATARA ,

AGREE to act as TRUSTEE as above mentioned.
THE OFFICIAL seal of the above named was hereunto affixed in the presence
of___________________________________________
____________________________________________ Signature
_____________________________________________
_____________________________________________
______________________________________________
who in token thereof have hereunto signed their names in the presence
of____________________________________ Signature
51
*State the amount calculated on the basis of the appropriate scales given at the end of this
chapter.
@ Use this clause in case where the policy contains double indemnity benefit for death by
accident.
** To be used where the policy moneys are payable otherwise than in one lump sum.
Clause No 74 Form No 3228

Re: Clause applicable to divers
Notwithstanding anything within-mentioned to the contrary, it is hereby declared

and agreed that in the event of death of the life assured taking place due directly or
indirectly as a result of his being engaged in (i) duties involving handling of explosives
and (ii) duties connected with any type of salvage work in the course of his duties as a
Diver or otherwise, the amount payable under this policy shall be limited to :
(i) a sum equal to the total amount of premiums (exclusive of extra premiums) paid under
the policy, without interest, less any sums paid by the Corporation in respect of bonuses in
cash, portions of sum assured or surrender value or otherwise,
OR
52
(ii) surrender value of the policy,
Whichever shall be the greater, but shall not exceed in any case the amount which would
p.Sr. Branch Manager
Clause No. 75 Form No. 3229

War risks exclusion clause
Notwithstanding anything within mentioned to the contrary it is hereby declared and

agreed that in the event of the death of the life assured taking place due directly or
indirectly as a result of his being engaged in (i) duties involving handling of explosives
and (ii) duties connected with any type of salvage work in the course of his duties as a
diver or otherwise, the amount payable under this policy shall be limited to:
(i) a sum equal to the total amount of premiums (exclusive of extra premiums) paid
under the policy, without interest, less any sums paid by the Corporation in respect of
bonuses in cash, portions of sum assured or otherwise or of surrender value or otherwise
O
R
(ii) the surrender value of the policy,
Whichever shall be the greater but shall not exceed in any case the amount which would
otherwise have been payable, at death.
53

Re: Satisfactory Medical evidence at vesting date clause
Notwithstanding anything within mentioned to the contrary, it is hereby declared and agreed
that the continuance of this assurance after the Deferred date shall be subject to the condition
that a medical report and such special medical reports that the Corporation may require on the
life of the life assured by appointed medical examiners of the Corporation shall be submitted to
the Corporation within a period of one month preceding the Deferred Date and the Corporation
shall be satisfied on the basis of such medical report/s not being submitted to the Corporation as
aforesaid or the Corporation not being satisfied that that the Life Assured is assurable at
ordinary rates on the basis of such medical report/s, the assurance shall cease and terminate as
on Deferred Date and in such event a sum of money equal to the Cash Option or Guaranteed
Surrender Value whichever is payable in terms of the policy conditions, of the medical reports
submitted as aforesaid the Corporation is agreeable to continue the assurance and the policy
holder is agreeable to the terms so offered, the assurance may be continued on such agreed
terms. Fees for the medical reports referred to herein above shall be paid to the medical
examiners in advance by the holder of the policy.
p.Sr./ Branch Manager
54
Proposal Clause No 77 Form No 3219 A
(Corresponding To Addendum Nos 7, 8 or 9)

Form of Endorsement for use in case where United Commercial Bank has been appointed
as a Special Trustee
WHEREAS I, ------------------------------------------------------------------------------------------

Corporation of India numbered----------------for the sum of Rs ------------expressed on the
face of the policy to be for the benefit of my (1) --------------------------------------------
(Relationship and name/s and age of the Beneficiary/ies)
and WHEREAS under Section 6 of the Married Women’s Property Act, 1874, the said
Policy shall enure and be deemed to be a trust for the above mentioned beneficiary /
beneficiaries AND WHEREAS the UNITED COMMERCIAL BANK having upon my
request agreed to act as Special Trustee of such trust, as is evidenced by their endorsing
their acceptance and concurrence at foot hereof, Iam desirous of appointing them as Special
Trustees of the said trust up on the terms hereinafter mentioned.
NOW THESE PRESENTS WITNESS that I, ---------------------------------------------------

do hereby appoint United Commercial Bank (hereinafter referred to as “Bank”), the Special
Trustee of the said trust to receive from the Life Insurance Corporation of India the amount
of the said policy and to hold such amount upon trust first to reimburse unto themselves all
costs, charges and expenses incurred if any, in realizing the amounts, next to pay the whole
of the balance in their hands to my said*_________________________in accordance with
the trust declared in the (Relationship and name of the Beneficiary)
within policy. AND I HEREBY DECLARE THAT the Bank in the discharge of its duties
and in the exercise of all its powers may act by its Officer or Officers appointed by the
Bank in that behalf and may employ solicitors or any professional advisers and agents to
transact all or any business of whatsoever nature required to be done in the premises of the
said trust and shall be entitled to be allowed and be paid our of trust all charges and
expenses so incurred and may (without being liable to account for any profit thereby
made)act as Banker and retain on Current or Savings account in connection with the trust
premises and shall be entitled to be allowed and paid such charges, expenses, interest and
55
commission as it charges its customers in the ordinary course of its business. The Bank is
hereby authorized to charge its commission at the rate of *_____________percent on the
claim amount subject to a minimum of Rs *__________and such amount of the
commission shall be a first charge on the premises of the said trust.

WITNESS:
Signature:
Full Name and
Address: Signature of the Life Assured.
WE, UNITED COMMERCIAL BANK, do hereby accept the trust herein above
contained and agree to act accordingly.
In witness whereof Shri _____________________________________the duly

constituted Attorney of UNITED COMMERCIAL BANK has for and on behalf of the
Bank hereunto set his hand this day of ___________________20_____at______
Signature of the Attorney of the Bank

SIGNED & DELIVERED for and on behalf of UNITED COMMERCIAL BANK by
_________________________its duly constituted attorney in the presence of
Signature of the witness :-
* State the amount calculated on the basis of appropriate scales given at the end of the
Manual.
56
Proposal Clause No 78 Form No 3219 B
(Corresponding To Addendum Nos 7,8 or 9)

Form of Endorsement for use in case where Syndicate Bank has been appointed as a Special
Trustee
I,------------------------------------------------------------------------------------------
(Name of the Life Assured and address)______________________________________
the assured under the within policy of assurance expressed on the face thereof to be for the
benefit of my (Relationship and name/s and age of the Beneficiary/ies)
under Section 6 of the Married Women’s Property Act, 1874, do hereby appoint
SYNDICATE BANK, a Bank constituted and functioning under the provisions of the
Banking Companies (Acqusition and Transfer of Undertakings) Act, 1970, with its head
office situated at Manipal in South Kanara District of Karnataka State, (hereinafter referred
to as “The Bank”) Special Trustee to recive from the Life Insurance Corporation Of India,
all moneys due under the policy when the same become payable under the terms thereof
and to hold the same upon trusts powers and provisions expressed in the said policy and
subject to the conditions mentioned herein AND I HEREBY declare that the Bank in the
discharge of its duties and in the exercise of all its powers as such Special Trustee as
aforesaid may act by its Officer or Officers appointed in that behalf and may employ
Lawyers, Solicitors, or other agents to transact any business required to be done in the
premises including the receipt and payment of money and may without being liable to
account for any profit thereby made, retain as Bankers on Current Account, Savings Bank
Account or Deposit Account or advance all moneys necessary or convenient to be retained
or advanced as aforesaid in connection with the Trust premises and shall be entitled to
beallowed and paid such charges, expenses,interest and commission it charges its as
customers in the ordinary course of its business and the Bank shall also be entitled to
remuneration in accordance with its scale of fees now in force.
(Signature of Life Assured)

Signed and delivered by the above named (name of the
assured)……………………………………………………………………. In presence of:
Witness:
Full Name:
Occupation & Address : (1) Signature
Full Name:
Occupation & Address (2) Signature
57
WE, SYNDICATE BANK, do hereby accept the Trust herein above contained and agree to
act as Special Trustee accordingly.
IN WITNESS WHEREOF Shri_____________________________________the duly

constituted Attorney of SYNDICATE BANK has for and on behalf of the Bank hereunto
set his hand this _______day of ___________________20_____(at Manipal.)
Signature of the Trustee Bank.
58
Proposal Clause No 79 Form No 3219 C
(Corresponding To Addendum Nos 7, 8 or 9)

Form of Endorsement for use in case where Maharashtra Executor & Trustee Co.Ltd., has
been appointed as a Special Trustee
I,______________________________________________________________________
(Name of the Proposer & Address)
________________________________________________________________________
the assured under the within policy of assurance expressed on the face thereof to be for the
benefit of my________________________________________ aged -
________years_______________________________________________
(Relationship and name of Beneficiary)
(hereinafter referred to as the Beneficiary/ies”) under Section 6 of the Married Women’s
Property Act, 1874, do hereby appoint MAHARASHTRA EXECUTOR & TRUSTEE
CO.LTD., a company registered under the Indian Companies Act 1913,having its Head
Office situated at Maharashtra bank Building,Bajirav Road,1177,Budhwar
Peth,Pune,411003, (hereinafter referred to as “Trustee Company”) as Special Trustee to
receive from the Life Insurance Corporation Of India, all moneys due under the policy
when the same become payable under the terms thereof and to hold the same upon trust
powers and provisions expressed in the said policy and subject to the conditions mentioned
herein AND I HEREBY declare that the Trustee Company in the discharge of its duties and
in the exercise of all its powers as such Special Trustee as aforesaid may act by its Officer
or Officers appointed in that behalf and may employ Lawyers, Solicitors, or other agents to
transact any business required to be done in the premises including the receipt and payment
of money and may without being liable to account for any profit thereby made, retain as
Special Trustee on Current Account, Savings Bank Account or Deposit Account or advance
all moneys necessary or convenient to be retained or advanced as aforesaid in connection
with the Trust premises and shall be entitled to be allowed and paid such charges, expenses,
interest and commission as it charges its customers in the ordinary course of its business
and the Trustee Company shall also be entitled to remuneration in accordance with its scale
of fees now in force.
(Signature of Life Assured)

Signed and delivered by the above named (name of the
assured)……………………………………………………………………. In presence of:
Witness:
(1) Signature: (2) Signature :
Full Name: Full Name :
Occupation : Occupation:
Address : Address :
WE, THE MAHARASHTRA EXECUTOR & TRUSTEE CO, PUNE, do hereby accept the
Trust herein above contained and agree to act as Special Trustee accordingly.
59
IN WITNESS WHEREOF Shri_____________________________________the duly
constituted Attorney of The Maharashtra Executor & Trustee Co Ltd, Pune has for and on
behalf of the Trustee Company hereto set his hand this _______day of
___________________20_____(at Pune.)
Signature of the Trustee Company.
SIGNED & DELIVERED for and on behalf of the Maharashtra Executor &Trustee Co.
Ltd., by Shri____________________its duly constituted attorney in the presence of
______________________
Witness:
(1) Signature: (2) Signature :
Full Name: Full Name :
Occupation : Occupation:
Address : Address :
Proposal Clause No 85
LIFE INSURANCECORPORATION OF INDIA
60
Exclusion Clause restricitng Accident benefit, Permanent Disability benefit and Extended
Permanent Disability Benefit whenever occupational extra is charged
Whenever occupational extra is chargeable, DAB, PDB and EPDB will be allowed subject
to imposing Clause 85. The wordings of Clause 85 are reproduced below for ready
reference.
“Notwithstanding anything within-mentioned to the contrary, it is hereby declared and

agreed that Double Accident Benefit including Extended Permanent Disability Benefit and
Disability Benefit shall not be applicable if the death or disability of the life assured shall
take place as a result of accident while the life assured is engaged in the hazardous
occupation”.
Proposal Clause 86
Exclusion Clause for sum assured to persons engaged in hazardous occupations and who do
not wish to pay occupation extra
61
If a life to be assured does not want to pay occupational extra, his proposal can be
considered without charging occupational extra subject to imposing the following Exclusion
Clause No. 86:

agreed that if the death of the life assured shall occur as a result of or from any cause arising
out of the life assured engaging in the hazardous occupation, the amount payable under the
policy shall be limited to either-
i. A sum equal to the total amount of premiums (exclusive of extra premiums) paid
under the policy, without interest, less any sums paid by the Corporation in
respect of bonuses in cash, portions of sum assured, or
ii. The surrender value of the policy,
whichever shall be the greater but shall not exceed in any case the amount which would
otherwise have been payable at death.”
62
FORMS RELATING TO AGE PROOF
Form No 3260

________Branch Office Annexure “A” BR CODE NO__________
Statement to be submitted by the Proposer/Agent/Dev Officer when standard age proof

viz. School/ University/Birth Certificate is not submitted with the proposal.
1. Name of the proponent
2. Place and Date of Birth
3. Proponent’s educational qualification
and year of leaving School or College
4. Proponent’s Occupation
5. His/ Her Employer’s Name and Address
6. Nature and Age Proof submitted
63
7. Reasons for not submitting a standard
proof of age
(a) If the proponent is educated, state why a
School/ University Certificate is not submitted
(b) The reasons why birth certificate cannot be
submitted
(c ) If the proponent is in service, state why an
extract from service register cannot be
produced
( d) If the submitted age proof is either an
elder’s declaration or self-declaration,
state reasons for the same
( e) If the submitted age proof is horoscope,

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 / DO Signature of the proposer
I have discussed the question of standard proof of age with the proposer and I am
satisfied that he / she cannot submit a standard proof of age for the following reasons.
REASONS:
I further certify that according to my estimation his / her apparent age is ______years
Signature of the Agent
I have discussed the question of standard proof of age with the proposer and I am
satisfied that he/ she cannot submit a standard proof of age for the following reasons.
REASONS:
I further certify that according to my estimation his / her apparent age is ______years
Signature of the Dev Off. / ABM(S)
64
Form No 3261
Proposal No.
Policy No.
Note: This form must be STAMPED BEFORE EXECUTION with a Special Adhesive
stamp of appropriate value or in the alternative the wordings of the Declaration must be
copied out on a Non-judicial (General) stamp paper of appropriate value (If executed in the
Indian Union), If executed outside the Union stamp only such value as may be required in
terms of stamp regulation of the place must be affixed to it.
DECLARATION OF AGE
(To be completed in the presence of a Magistrate or a Notary or any other officer
empowered to administer oaths in Non-court matters by a Relative CONSIDERABLY older
than the party whose age is to be proved or failing such a relative or by a friend also
CONSIDERABLY older than the party. The Declarant must have personal knowledge of
the date of birth.
(Signature in Vernacular must have its English translation written underneath them)
65
Full Name, occupation and address {……………………………………………
of the party whose age is to be proved ……………………………………………
Full name, occupation and address of {I,………………………………………….
the declarant, his own age and relationship …………………………………………...
to the party.
do hereby solemnly affirm and declare that above mentioned……………………………

son of ……………………………………who is (state relationship)………………………...
…………………………who (if not related)has been known to me for……………………...
…………………years was born at………………………..on the …………………………...
day of ……………………………….one thousand……………………………..hundred…...
…………………………………………………………
I am able to state with certainty as……………………………………………………………

Describe here the circumstances upon {………………………………………………………
Which the declarant found his knowle-{……………………………………………………...
dge of birth {……………………………………………………..
I make this solemn declaration solemnly and sincerely believing the same to be true
and knowing that on the faith thereof the Corporation has agreed to admit the gae of the
above mentioned policy holder and that this declaration would be receivable as evidence in
any future litigation that mey take place in connection with the policy and that to the best of
my knowledge and belief no documentary evidence is available in proof of the date of birth
of the above mentioned policy holder.
Signature of elderly relation or friend of the Proposer / Life Assured………………………

Occupation………………………………..
Address…………………………………..
DECALRED BEFORE ME at and certified

that the declaration has been read over to and understood by the declarant this
Day of 20 .
(Magistrate or a Notary or any Officer empowered to

administer oaths in non-court matters.)
66
Form No. 5096 (R)
3260/3179-A(Merged)

______________Division
Branch Office ……………………………………..
Proposal No.
Policy No.
DECLARATION OF AGE
I……………………………………….son/daughter/wife of……………………
by occupation ……………………………….residing at ………………………….do hereby
affirm and declare that to the best of my knowledge and belief, I was born
at…………………………………..
on………………………………….. and that I am of ………….years of age and that I have
no other
(state date of birth in known)
reliable documentary evidence of age to produce in proof of my age. I make this
declaration conscientiously believing it to be true and knowing that on the faith hereof the
LIFE INSURANCE CORPORATION OF INDIA will admit my age in their records.
67
Signature of proposer / Life Assured
DECLARED BEFORE ME at …………………………….and certified that the declaration

has been read over to and understood by the declarant this ………………… day of
………………20 .
Secretary of the Panchayat/

Member of the Panchayat/
Block Development Officer/
Thasildar/Gazetted Officer/
Class I Officer/Dev. Officer/
Of LIC. Signature of Declarant.
*To be completed by an Appointed Medical Examiner of the Corporation
I hereby certify that Shri/Smt…………………………………………..was

identified before me by Shri ………………………………………….and from his/her
appearance he/she looks to be approximately………………………years old.
Signature of Proposer / Life Assured. Signature of Medical Examiner*
Note : This form can be used only if the total sum proposed including all the previous
policies does
Not exceed Rs.50,000.
** For cases under non medical scheme this certificate should be completed by the
Development Officer / ABM(S) / BM.
Dear Sir,
Re : My proposal dated …………………………
With reference to my above proposal, I hereby agree to the extra premium being
charged at the rate of Rs………….. per thousand sum assured per annum on account of age
admission on the basis of self-declaration.
Signature of Proposer / Life assured.
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 :
3. Proponent’s educational qualification and year of:

Leaving School or College
4. Proponent’s occupation :
68
5. His employer’s name and address
6. Nature of age proof submitted :
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.
(v) If the submitted age proof is either an elder’s :
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 200 .
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)
69
Form No 5220

____________Division
Proposal No…………………….
Policy No……………………….
Note: This form must be STAMPED BEFORE EXECUTION with a Special Adhesive
Stamp of the value of Rs………………… or in the alternative, the wordings of the
Declaration must be copies out on a Non-judicial(General) stamp paper of
Rs………………….(if executed in the Indian Undion). If executed outside the Union
stamp of only such value as may be required in terms of stamp regulations of the place must
be affixed to it.
DECLARATION OF AGE
(To be completed in the presence of a Magistrate or a Notary or any other Officer

empowered to administer oaths in non court matters by the person whose age is to be
proved)
(Signature in vernacular must have their English translation written underneath them.)
I …………………………………… son of …………………………………… by

occupation ……………………………………………… residing at
……………………………….. do hereby solemnly affirm and declare that to the best of my
knowledge and belief, I was born at ……………… on the ……………. Day of
……………….one thousand ………………. Hundred ……………………. And am of
……………………… years of age.
I make this solemn declaration solemnly and sincerely believing the same to be true
and knowing that on the faith hereof the LIFE INSURANCE CORPORATION OF INDIA
will admit my age in their records and that this declaration would be receivable as evidence
70
in any future litigation that may take place in connection with the policy and that to the best
of my knowledge and belief no other reliable documentary evidence is available in proof of
my age.
Signature of ( Proposer / Life Assured)
Declared before me at ……………………………….. and certified that the declaration has

been read over to and understood by the declarant this …………….. day of
……………………200 .
(Magistrate or a Notary or any officer

empowered to administer oaths in
non-court matters)
71
MEDICAL QUESTIONNAIRES
72
Form 3322
ADDITIONAL FORM FOR ASTHMA/BRONCHITIS

Full Name of the life to be assured ______________________________________Age
______________
Occupation and exact nature of duties___________________________________________
QUESTIONS TO BE ANSWERED BY THE PROPOSER/LIFE ASSURED.
1. (a) Was your first attack in childhood or in

adulthood? Please give exact age at onset
(b) Have the attacks of childhood asthma

disappeared on reaching age 20 years? If
not, are they of same frequency and
severity as earlier childhood attacks?
(c) How many attacks on an average do you

have in a year and when was the last
episode?
(d) How long do the attacks usually last?
(e) Does your work environment have high

level of pollution?
(f) How many days (total) you have been

away from work due to asthma during
last 2 years?
2. (a) What treatment do you take for asthma

usually?
(b) Are you required to take Corticosteroids

(Medicines like PRedhisolene etc) for
relief and if so for how many years and
what dose?
(c) Are you still taking such Medicines as

Cortico Steroids?
3. (a) Are you a Smoker or a Non-Smoker?
73
(b) If a Smoker, how many cigarettes, bidis
etc., per day?
(c) If a smoker, for how many years you

have been a smoker?
(d) Do you have a Smoker’s Cough?
(e) Are you taking treatment for chronic

bronchitis? If so, give details.
(f) Have you given up smoking? If so, total

period of abstinence.
(g) Is there any family history of asthma? If

so, mention the number of family
members and their relationship.
(h) Have you ever been hospitalized for

treatment of acute asthma? If so, details
with particulars.
(i) Have you ever undergone pulmonary

Function Test/s or Chest X-Ray
examination/s? If yes, submit copies of
the Reports
4. Do the attacks occur during any particular

season of the year?
5. What is the level of your effort/exercise

tolerance? Mention distance you can walk
and number of stairs you can climb without
causing breathlessness.
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 Witness:
Occupation:
Address: Signature of the Proposer
Questions to be answered by the Family Physician / Personal Medical

Attendant or the Medical Examiner
1. Is this person, in your opinion, a case of
74
acute intermittent asthma? Or Caronic
obstructive Pulmonary Disease (COPD) Cor
pulmonale
2. Do you have any reasons to suspect Cardiac

Asthma as a cause of breathlessness in this
person. If yes, please give your reasons.
3. Do you find any evidence of congestive

cardiac failure clinically, secondary to
COPD?
4. Remarks :
Signature of the Medical Examiner

Name:
Qualifications / Code:
Place: Seal
Date :
75
Form No.3323
BRONCHITIS QUESTIONNAIRE
Proposal No. ………………………………….

Agent’s Name …………………………………………Agent’s Code No. ………………
Full name of the Proposer ……………………………………….. Age …………………….
Questions to be answered by the proposer
1 (a) Give the dates of

(i) the first attack (a) (i)………………………………………….
(ii) the latest attack (ii) …………………………………………
(b) How many attacks do you (b) ………………………………………………
get in a year?
(c) Are attacks increasing or (c) ………………………………………………
decreasing in number and/or severity?
(d) How many days have you lost d) …………………………………………………
from work during the past two years
on account of the condition?
2. Do attacks occur at any particular
time of the year?
3. (a) Do you bring up any sputum ? (a)

If yes, what is its colour ? ……………………………………………………..
(b) Has the sputum ever been brown (b)
or blood stained? ……………………………………………………..
4. Are you short of breath or do you
wheeze on exertion ?
5. Please give the name and full
address of your usual medical
attendant.
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

…………………. 200….
…………………………..
Questions to be answered by the Medical Examiner Signature of the Proposer
1. Are there at present any physical signs of bronchitis ?

2. Are there any signs of emphysema?
3. What in your opinion is the case of the condition?
4. Are you in any way suspicious of tuberculosis :
76
Date : ………………….
…………………………………….
Qualifications. ………………………………….
Code No………………………………………….
Name and Address ………………………….
(In Block Letters) …………………………..
……………………………………………………
77
Form No 3334 Revised
C. N. S. QUESTIONNAIRE
Division___________ Branch Officer ___________
Proposal No._____________
Full Name of the Proposer ____________________________ Age _______
Special Questions in relation to the examination of Central Nervous System

To be completed by the Medical Examiner
The medical examiner should give his remarks against each item mentioned below:
1. Headache
2 Memory
3 Temper
4 Speech
5 Sleep
6 Delusions
7 Fits, Fainting, Giddiness, epilepsy
8 Ataxia
9 Nervousness
10 Tremors
11 Sight
12 Strabismus
13 Hearing / Tinnitus / Ear discharge
14 Taste
15 General weakness
16 Type of paralysis
Upper Motor neuron type
Lower motor neuron type
17 Cramps
18 Sphincters:
Rectal
Vesical
19 Reflexes
Elbow
Wrist
Knee
Ankle
Planter Reflex
20 Sensory functions
21 Motor system:
i. Involuntary movements
ii. Atrophy or hypertrophy
iii. Tone
iv. Power
v. Co-ordination
78
22 Trophic changes
23 Posture and Gait
24 Any mental retardation/disorder
25 General remarks
Dated at _________________on the _______day of ______20
_______________________ ______________________________
Signature of the proposer / Signature of the Medical Examiner /
Policyholder Medical Attendant
Code No._____________
Qualifications___________
Registration No.___________
Address _________________
79
CHEST PAIN QUESTIONNAIRE Form No 3333
To be completed by the Proposer
Full name of the proposer:
1 What was the date of the first attack of chest pain?
2 Have any attacks occurred subsequently? YES / NO

If YES, please provide dates.
3 What was the nature and severity of the pain? eg very

severe, crushing, vice-like, sharp, stabbing, dull ache,
vague discomfort
4 What was the location of the pain? eg central, in the left

or right side of the chest, across the front of the chest,
elsewhere in the chest
5 Did the pain radiate outside the chest? eg to the shoulders,

arms, jaw, abdomen
6 What was the mode of onset? eg sudden, gradual, at rest,

only on exertion ceasing with rest, only with certain
postures, worsened by deep inspiration
7 How long did the pain last?
8 Were you given any treatment or undergo any YES / NO

investigations?
If YES, please provide details including names of any
medication.
80
9 Have you required time off work due to chest pain? YES / NO
If YES, please provide details including dates and
duration of time off work.
10 Please provide any additional information on your

condition which you feel will be helpful in processing
your application.
I declare that the answers I have given are, to the best of

my knowledge, true and that I have not withheld any
material information that may influence the assessment or
acceptance of this application.
I agree that this form will constitute part of my

application for life assurance and that failure to disclose
any material fact known to me may invalidate the
contract.
Signature of Proposer
Date
81
Form No._______
Division ____________ Branch Office _______________
DEFORMITY QUESTIONNAIRE
Name of the proponent / Life Assured_____________________________________
Questions to be answered by the proponent’s / policyholder’s Personal Medical Attendant /

Medical Examiner regarding Deformity/ies and / or Impairment/s
1. a. What is the cause of deformity?

Whether it is
i. Congenital
ii. Due to an accident or injury
iii. Due to any underlying disease?
a. Since when the deformity is present?
2. If the deformity is due to any underlying disease, please
state the following:
i. What was the disease leading to deformity?
ii. When did it occur?
iii. Whether the disease is stationery or progressive?
iv. If stationery, since when
3. Does he/she have control on bowel movements and
bladder?
4. Exact parts of the body affected and extent
5 Are there any restrictions in movements and function of
the limbs or affected parts? Please give degree of disability
6. Has he/she a limp?
7. Whether he /she can walk and run fast without any aid (in
case of deformity in the leg)?
8. Can he/she squat, sit and get up properly?
9. Whether the affected limb is shorter than the other , and if
so, to what extent (in cms)
10. If the deformity is due to poliomyelitis, please state
whether the wasting of muscles is
i. mild
ii. moderate
iii. severe
11. How many limbs are affected?
12 Are there any respiratory complications?

If yes, give details
13 Is there any restriction in movement of any of the fingers?

Are any of the fingers removed?
If so, upto which phalanx.
82
Whether thumb and forefinger have been affected /
removed?
14 a. Whether he / she can lift articles without any difficulty
and hold the articles without losing the grip (in case of
deformity in the hands)?
b. Is the grip firm and strong?
15 Are there any residual complications?
My diagnosis as to the cause of the disability is ________________________________

_______________________________________________________________________
I do for the reasons explained below / do not have any reason to suspect on clinical grounds
a recent deterioration causing more pronounced disability:
a. He / she is able / not able to perform routine self-care activities.

b. He / she is / is not required to use wheel chair / crutches.
c. Any other factors which are likely to add to the risk on account of the deformity
/ ies.
Please submit details of previous treatment, previous special reports, x-rays etc. for perusal
and return.
Dated at _________________on the _______day of ______20
_______________________ ____________________
Signature of the proposer / Signature of the Medical Examiner /
Policyholder Medical Attendant
Code No._____________
Qualifications___________
Registration No.___________
Address _________________
83
DIABETES QUESTIONNAIRE
Form No 3328
To be completed by the Proposer:
Full name of the proposer:
1 When was diabetes first diagnosed?
2 Regarding your treatment:

a Do you take tablets? YES / NO
If YES, please state the name of the tablets.
b Do you take insulin? YES / NO

If YES, please state type of insulin and dosage (morning
and evening).
c Has your treatment been changed in the last 2 years? YES / NO
If YES, please provide full details.
3 Do you follow a strict diet? YES / NO
4 Regarding the monitoring of your condition:
a Please provide the name and address of the doctor or
clinic supervising your treatment.
b How often do you attend for monitoring?
c When was your last consultation?
d How often do you test your blood or urine for glucose?
e Please indicate your usual test results by circling as
appropriate:
i) blood glucose:
below 8 8.1 - 9.0 9.1 - 11.0 11.1 or more
ii) urine glucose:
negative + ++ +++ or more
f Please provide the dates and results of your last 2 HbA1c
(glycosylated haemoglobin) tests, if known.
5 Since your treatment began, have you ever had a diabetic YES / NO
84
(hyperglycaemic) or insulin (hypoglycaemic) coma.
If YES, please provide full details including date(s).
6 Have you ever had any of the following?
a Problems with your eyes YES / NO
b High blood pressure YES / NO
c Heart or circulatory trouble YES / NO
d Albumin or protein in your urine YES / NO
e Numbness or tingling in your feet or legs YES / NO
If YES, to any of the above, please provide full details.
7 Have you lost time off work with diabetes or associated YES / NO
conditions?
8 Please provide any additional information on your
condition which you feel will be helpful in processing
your application.
I declare that the answers I have given are, to the best of
my knowledge, true and that I have not withheld any
material information that may influence the assessment or
I agree that this form will constitute part of my
application for life assurance and that failure to disclose
any material fact known to me may invalidate the
contract.
Signature of the Proposer
Date
85
DIABETES QUESTIONNAIRE Form No 3329
To be completed by the attending physician or diabetic clinic.

Full name of proposer:
1 When was diabetes diagnosed?
2 What treatment has been prescribed?
a) diet only
b) oral hypoglycaemics (please state drug and dosage)
c) insulin (please state type and dosage)
3 How well does the patient control his/her condition?
4 If you are the attending physician, does the proposer attend a
diabetic clinic? If so, please provide the name and address of clinic,
and date of last known attendance.
5 Have there been any episodes of hypoglycaemia requiring
intravenous glucose, or hospital admission due to diabetic coma or
ketoacidosis? If so, please provide details.
6 Please provide details of recent blood sugar levels.
7 Please provide details of any glycosylated haemoglobin
measurements.
8 Is there evidence of any of the following?
a) Retinopathy YES / NO
b) Nephropathy YES / NO
c) Neuropathy YES / NO
d) Ischaemic heart disease YES / NO
e) Peripheral vascular disease YES / NO
If YES, please provide details.
Signed
Date
86
Form No 3340

EPILEPSY QUESTIONNAIRE
Name of the Proposer………………………. Age………Prop No……………
1. Give the date of first fit, convulsion or

seizure:
2. How frequently did the attacks occur?
3. Were the attacks increasing in severity?
4. Were the intervals (Between two attacks)
lengthening ?
5. Was there complete unconciousness during
the attacks?
6. Were the spasms clonic in character?
7. Did you ever bite your tongue during the
attacks?
8. Did you go to sleep after the fits?
9. Was there any involuntary micturition?
10. What was the type of treatment given to
you?
11. Are you taking any drugs now? If not now,
state when they were last taken
12. Since when are you free from any
manifestation of Epilepsy
13. Were any investigations like X-Ray,ECG,
CSF, Blood examinations done? If so,give
details
I hereby agree that the foregoing questions and answers shall form part of the Form of
Proposal for insurance made by me to the Life Insurance Corporation of India on the
………..day of ………20 and they shall be of the same effect as if contained in the
Form of Proposal for insurance.
Dated at…………….this…………..day of …………..20
……………………… …………………………
Signature of the medical examiner Signature of the Life Proposed
Medical Attendant’s Report :

1. Did the attacks resemble the Petit Mal or the Grand Mal variety ?....................
2. Are there scars on the tongue or elsewhere which might be due to Epileptic
seizures ?..........................
3. Has there been any mental retardation?........................
4. What are the effects of drugs and fits on his mental conditions ?..........................
……………………………………………………………………………………………..
………………………………………………………………………………………………
………………………………………………………………………………………………
Remarks :…………………………………………………………………………………..
………………………………………………………………………………………………
87
…………………………….
Signature of the Medical Attendant
Name :………………………
Qualifications:………………
Address :…………………….
88
FILARIASIS FORM Form No 3332
Proposal No…………..
Additional Queries to be answered by the Medical Examiner in cases where a Proposer has
a past or present history of Filariasis or Elephantiasis.
Proposal on the life of………………………………….Age…………………..

1. Has the proposer ever suffered from or is
now suffering from attacks of the diseases
known as Filariasis, Lymphangitis,
Chyluria,Elephantiasis,
2. If so, state the variety of the disease :
(a) Whether it is Filariasis with an (a)……………………………….
inflammatory swelling and redness of the
skin, fever and pain, with mild or severe
constitutional disturbance and whether one
or more limbs of the upper or lower
extremities
(b) Whether it is of the scrotum and / or (b)………………………………..
penis (if a male) or of the external organs
of generation (if a female)
(c ) Whether there has been any ulceration ( c)……………………………….
or discharge of foul matter (or lymph) from
the ulcerated skin, at any time.
(d) Whether there has been any passage of
a milky fluid known as Chyle (Chyluria) or (d)…………………………………
a mixture of blood and chyle
(Haematochyluria) from urine, and if so,
when, for how long and how often
3. State the date of the first and last attacks,
the number and frequency of the recurrent
attacks, whether mild or severe and their
duration.
4. Give the approximate size, whether large or
small and the circumferential
measurements of the swelling in cms at its
thickest and thinnest part.
5. Since how many months or years have The
attacks ceased completely and has there
been any perceptible increase in the size of
the swelling during the last two or three
years
6. Are the swellings of such size as to interfere

materially with the freedom of easy
movements, exercise and daily work.
7. Can the proposer submit a certificate from
his usual medical attendant, testifying to a
89
complete cessation and absence of even a
single attack during the last three or five
years.
Place :……………………… Signature of the Medical Examiner………..
Date :………………………. Name……………………………………

Code No…………………………………
Qualification……………………………
Address………………………………….
90
DIVISION Branch Office ________________
PERSONAL HISTORY OF GALL-BLADDER DISEASE Form No. 3327
QUESTIONS TO BE ANSWERED BY THE PROPOSER

Proposal No. __________________Agent’s Name and Code No.
________________________________________
Full Name of the Life to be Assured ___________________________________________ Age
__________________
(IN BLOCK LETTERS)
1. a) Have you ever had attacks of pain in the region of a)
the gall-bladder?
b) If yes, give: b)
i) The date and duration of the first attack i)
ii) The dates and duration of subsequent attacks ii)
iii) The date and duration of the last attack iii)
2. Was the pain colicky in nature, or was it dull and
continous?
3. a) Were any of the attacks accompanied by a)
jaundice?
b) If yes, give dates and durations b)
4. Have you had any digestive symptoms accompanied

by loss of appetite, belching of gas, pain or distension
at the pit of the stomach, nausea, vomiting, constipation
etc, before or subsequent to the attacks of gall-bladder
trouble?
5. a) Were you confined to bed during any of the a)
attacks?
b) How long did each attack keep you from work? b)
91
6. a) Was an X-ray of gall-bladder taken? a)
b) If yes, give dates and findings, Please submit the - b)
ray plates with readiologist’s reports
7. a) Was an operation performed on your gall-bladder? a)
b) If yes, state (i) the date of the operation: and b)
(ii) Whether the gall-bladder was drained or
removed?
Please submit a certificate from the operating
surgeon which should give the reasons for the
operations its nature and findings.
8. a) Have you had any digestive disorders since the a)

operation
b) If yes, give details b)
9. Give the names and address of the doctors who

attended you
I agree that the foregoing questions and answers shall form part of the proposal for assurance made by
me to the Life Insurance Corporation of India on ____________________
Dated at ______________on this ______________ day of _________________ 20 _________
_______________________________________
___________________________________
Signature of the Medical Examiner Signature of the Proposer
Signature of Witness _________________________

Occupation __________________________________
Address _____________________________________
______________________________________________
QUESTIONS TO BE ANSWERED BY THE MEDICAL EXAMINER
1. Has the applicant any pain, discomfort or tenderness in the region of the
gall-bladder?
2. Is there any Jaundice present?
3. Did you find or have any suspicion of the applicant suffering from
disturbance of the digestive functions or having any digestive symptoms
such as anorexia, flatulence, epigastric pain, tenderness or gaseous
distension, nausea, vomiting, constipation, etc.?
92
4. Any further remarks you wish to offer
____________________________________
Qualifications
:_________________________________________
Code No.
:______________________________________________
Name and
Address______________________________________
(In Block Letters)
_______________________________________________
_________
Date :__________________
93
PERSONAL HISTORY OF AN OPERATION FOR GASTRIC OR DUODENAL ULCER

Form No. 3324
Proposal No.________________________________
Agent’s Name & Code
no___________________________________________________________________________
Full Name of the
Proposer______________________________________________Age____________________
__
Questions to be answered by the Proposer

1. (a) What was the date and duration of 1. (A)
the first attack of pain in the __________________________________
upper part of the abdomen? ____
(b) How many attacks have you had
since then? Give the date and (B) ___________________________________
duration
(c) Given the dates and duration of
(C) __________________________________
the last attack.
2. Was the condition diagnosed as 2.________________________________________

gastric or duodenal ulcer?
3. (A) What was the date of the 3. (A) __________________________________

operation?
Give the name and the address of
the operating surgeon.
(B) What is the nature of the
(B) ___________________________________
operation performed? State
whether ___________________________________
i) Gastroenterostomy i) ________________________________
ii) Substoal gastrectomy, or ii) ________________________________
iii) Vagotomy iii) ________________________________
(C)Were there any signs or suspicion of (C) ________________________________

malignancy present?
N.B.:-Please submit a certificate from the operating surgeon giving full details of the history of
illness, the nature of operation performed and the result of the same.
94
4. (A) Since when have you completely 4. (A) ________________________________
recovered after the operation?
(B) Have you been X-rayed since then? (B) ________________________________
If yes, please give the dates of the X-
ray examinations and submit the X-
Ray plates with the Radiologists’
reports thereon.
(C) Has there been any recurrence of (C) ________________________________
symptoms such as epigastric
discomfort, pain, nausea, vomiting,
indigestion, gaseous distension,
eructations, etc., since the operation?
IF yes, give full particulars.
(D)_________________________________
(D) Have you been observing any
restriction on or modifications in the
diet since the operation?
(E) (i) Did you lose weight in your (E) (i)_________________________
illness? If yes, how many kgs did you
lose
(ii) Have you regained the lost (ii)_________________________
weight by now?
(iii) Is the weight now stationery?
(iii)_________________________
If yes, since when
I agree that the following questions and answers shall form part of the proposal for
assurance made by me to the Life Insurance Corporation of India………………….
Dated at………………….on the ………………………..day of …………….20…………
Signature of Witness:……………………..
Occupation:……………………….
Address:…………………………..
…………………………………….. ………………………
Questions to be answered by the Medical Examiner

1. Is there any tenderness,
rigidity or increased
resistance over the area of
the stomach and duodenum
at present?
95
2. Is the scar of operation firm
and healthy?
3. Is there any bulging or hernia

present at the site of the
operation?
4. Does the applicant appear
anaemic or to have lost
weight?
5. Any further remarks you
wish to offer
Date………… …………………………………
Qualifications…………………….
Code No…………………………..
Name and Address……………….
(in block letters)
……………………………………...
……………………………………...
96
Form No. 3330
GOITRE (WITH OPERATION)
Proposal No.___________________________
Full Name of the
Proposer_____________________________________________Age__________________

1. a) Give full history prior to the 1. a)
operation, including information _________________________________
regarding the approximate date when
____________________________________
the swelling was first noticed,
symptoms, diagnosis, treatment, name ____________________________________
of the doctor who treated you, etc. ____________________________________
b) Why was operation advised? b)

_________________________________
c) What was the date of operation? c)
N.B. Please submit a certificate from _________________________________
the operating surgeon, stating why the
operation was performed, what was
done, what was found and the results.
2. Since the operation 2.
a) Have you noticed your heart beating a) _________________________________
forcibly
i)_______________________________
i) after moderate exercise ii)_______________________________
ii) after excitement iii)______________________________
iii) at rest?
b) Do you perspire freely? b)_______________________________
c) Is your appetite good? c)_______________________________
d) Have you lost or gained any weight? d)__________________________________
If yes, how much?
3. Does your feet or ankles swell 3. _________________________________
97
4. Are there any signs of hyperthyroidism/ 4. _________________________________
hypothyroidism?
I agree that the foregoing questions and answers shall form part of the proposal for assurance
made to the Life Insurance Corporation of India
on__________________________________________
Dated at______________on the _______________ day of __________________20
98
Form No. 3330
[Goitre (with operation)] Form No. 3330

N.B. :- Please complete the Special Heart Report also.
1. Was the goitre removed on account of
toxic symptoms?
2. What type of goitre was found on

operation adenomatous or diffuse?
3. Are there any fine tremors of the tongue

or out stretched fingers?
4. Are there any signs of hyperthyroidism?
5. Is there any exophthalmos?
99
GOITRE (WITHOUT OPERATION) Form No. 3331
Proposal No.___________________________
Full Name of the Proposer_____________________________________ Age_______________

1. Since when has the swelling in the neck been
noticed?
2. a) Is the size of the swelling stationary?
b) Is the size of the swelling increasing or

decreasing? If yes in (a) or (b), since
when?
3. Does the swelling cause any discomfort?
4. a) Have you noticed the heart beating
forcibly i) After moderate exercise
ii) After excitement;, or
iii) At rest?
b) Do you perspire freely?
c) Have you noticed any undue nervousness
or fatigue?
d) Is your appetite good?
5. Have you gained or lost weight during the
last two years?
6. Have you undergone any treatment for
goitre? If yes, state
i) What was the diagnosis made by the
doctor?
ii) What was the nature of treatment?
iii) When was the treatment discontinued?
iv) The name and address of the doctor who
treated you.
7) Have you been advised or do you propose to
undergo an operation for goitre?
If yes, state why.
100
I agree that the foregoing questions and answers shall form part of the proposal for
assurance made to the Life Insurance Corporation of India on______________________
Dated at_________________on this_____________day of_________________20
Signature of the Witness______________________________

Name & Design. Of Witness___________________________
________________________________________
______________________________________________________
______________________________________________________

N.B. :- Please complete the Special Heart Report also.
1. a) i) Is the whole gland enlarged?

ii) If not, which part is enlarged?
b) Is the swelling firm, oft, nodular or

diffuse?
c) What is the size of the neck?

i) At the maximum circumference?
ii) At the minimum circumference?
2. a) Are there any fine tremors of the tongue or

outstretched fingers?
b) Does applicant perspire freely during

examination?
3. Are there any signs of hyperthyroidism
4. Is there any exophthalmos?
5. Any other remarks you may wish to offer
101
Date :
Name :_____________________________
Code No :____________________________
Qualifications:________________________
Address:_____________________________
102
HEARING QUESTIONNAIRE
Proposal No………………….
Name :……………………….
Type of voice Left Ear Right Ear

Without With Hearing Without Hearing With Hearing Aid
Hearing Aid Aid Aid
1)Whisper
Is the voice
heard? If so,
kindly indicate
whether it is
heard well or
with difficulty.
2) Ordinary
Conversation
Is the voice
heard ?
If so, kindly
indicate whether
it is heard well or
with difficulty.
3) Loud Voice
Is the voice
heard? If so,
kindly indicate
whether it is
heard well or
with difficulty.
Note: Answers to all columns should be given in cases where hearing aid is being used
while all other cases only answer to Column 2 & 4 be given.
………………………………. ………………………………..
Signature of the Proposer Signature of the Medical Examiner
103
HERNIA QUESTIONNAIRE
1. Name in full (in BLOCK LETTERS) :
2. State the type of hernia – Whether Inguinal, :

Ventral (Post – operative or umbilical)?
3. It is reducible or irreducible ? :
4. What is the size of Hernia in the scrotum? :

(in centimeters, if complete)
5. Is it on the right side or left side or double? :
6. Give the full history of Hernia Since :

When affected, whether primary of
Recurrent? Are there any complication or
Inflation, etc?
7. If the Hernia has been operated, place :
give date of operation and the result thereof.
8. Is a well-fitting truss being constantly worn? :
9. What is the nature of occupation? :

Does it require much moving about :
Does it require any mannual work ? :
10. Any other findings or remarks which :

in the opinion of the Medical Examiner is
likely to affect the longevity of the lfie :
proposed for assurance
Dated at____________ on the_____________ day of ___________ 200
Signature of the Proposer Signature of Medical Examiner
Name of the medical examiner

ME Code no.
Address :
104
High Blood Pressure Questionnaire- Form No 3339
To be completed by the Proposer
Full name of the Proposer:
1. When was blood pressure first diagnosed ?
2. Why was your blood pressure measured at that particular time? eg routine
examination, due to symptoms, etc
3. Do you know what your blood pressure readings were at YES / NO

diagnosis?
If YES, please provide details.
4. Have you had an ECG, x-ray, blood lipid test or other YES / NO
investigations?
If YES, please provide details including dates of
investigations and results.
5 Please provide details of your treatment. Include names of medication (eg
Moduretic, Navidrex, Aldomet, Inderal, Tenoretic, Tenormin, Trasicor
etc), dosage and how often taken:
a Currently
b In the past
6 Regarding the monitoring of your condition:

a Who is in charge of your follow-up?
b How often do you attend for follow-up?
c When was your last consultation? Please provide details of your blood
7 Have any abnormalities (eg protein, blood, etc) ever been YES / NO
found in your urine?
If YES, please provide date(s) and full details.
8 Do you smoke cigarettes? YES / NO
If YES, how many per day?
9 Have you lost significant time (eg weeks) off work with YES / NO
105
this condition?
10 Please provide any additional information on your condition which you

feel will be helpful in processing your application.
I declare that the answers I have given are, to the best of my knowledge, true and that
I have not withheld any material information that may influence the assessment or
I agree that this form will constitute part of my application for life assurance and that
failure to disclose any material fact known to me may invalidate the contract.
Signature of applicant
Date _________________________
106
High Blood Pressure Questionnaire- Form No 3339 A

To be completed by the attending physician
Full name of the

Proposer:…………………………………………..
1 When was your patient first noted to be hypertensive and
what were the blood pressure readings at that time?
2 Have investigations been made to determine the cause? If

so, what were the results and final diagnosis?
3 Has treatment with anti-hypertensive or other drugs been

given? If so:
a When did treatment commence?
b What was the average blood pressure immediately prior to

treatment?
c What drugs are being taken?
d Does your patient adhere strictly to the prescribed

treatment?
e Is the condition considered to be satisfactorily controlled?
f Please give a sample of the subsequent and current blood

pressure levels including dates.
g If treatment has been discontinued please give date of

cessation.
4 Have any complications of hypertension ever been noted?
107
If so, please give details including the dates and duration
of any time off work.
5 Please give the dates and results of any chest x-ray, ECG
or other investigations performed since treatment was
started.
Signed
Date
108
PERSONAL HISTORY OF INDIGESTION, DYPSPEPSIA,

GASTRIC OR DUODENAL ULCER (NOT OPERATED)ETC FORM NO 3325
Proposal No.________________________________
Agent’s Name & Code
_______________________________________________________________________________
Full Name of the Proposer
_______________________________________________Age______________________
Questions to be answered by the Proposer

1. (a) When did you first suffer from indigestion or
dyspepsia and for what period?
(b) How many attacks have you had during the last
five years?
(c) Give the date and duration of the last attack.
2. (a) What was probably the cause of these attacks of
indigestion?
(b) Were they mild or severe?
(c) Were they accompanied by acute pain or
frequent vomiting?
(d) Was there any haemorrhage or vomiting of blood
at any time?
If yes, state how often, give the dates and state
whether haemorrhage was small or profuse in
quantity.
(e) Were there any attacks of jaundice?
If yes, give the dates and durations.
3. Have there ever been any signs or suspicion of
gastric or duodenal ulcer?
4. Has an X-Ray examination of the digestive tract
after a barium meal ever been made? If yes, state the
dates of the examinations and their results and
submit the X-ray plates with the radiologists’ reports
thereon.
5. (a) How long were you under the treatment of a (a)
doctor?
(b) Have you been under treatment in a hospital or (b)
nursing home?
109
If yes, give full particulars
(c) Please send a report of your attending (c)
physician giving full details regarding your
ailment, investigations made and their results
and the nature of treatment given.
6. (a) Since when have you been completely cured of
your ailment?
(b) Have you been observing any restrictions on
diet since recovery?
(c) i) Did you lose weight during your illness and if
so, how many Kgs. did you lose?
ii) Have you by now regained the lost weight?
iii) Is the weight now stationary? If so, since
when?
7. Give the names and address of the doctors who
attended you.
I agree that the foregoing questions and answers shall form part of the proposal for assurance
made by me to the Life Insurance Corporation of India on_________________________
Dated at_____________on the ______________________day of_______________20

QUESTIONS TO BE ANSWERED BY THE MEDICAL EXAMINER
1. (a) Is there any tenderness, rigidity, or increased
resistance over the area of stomach and
duodenum?
(b) Is there any tenderness or rigidity over the region
of the gall-bladder or appendix?
2. Do you suspect the presence of gastric or duodenal
ulcer?
3. Does the applicant appear anaemic or to have lost
weight?
4. Any further remarks you wish to offer
_______________________________________
Date ________________________Qualifications:___________________________________
110
Code No: __________________________________________
Name and Address___________________________________
(In Block Letters)
___________________________________________________
___________________________________________________
111
PERSONAL HISTORY OF KIDNEY DISEASE, COLIC OR STONE ETC.

(Questions to be answered by the Proposer) Form No 3326
Proposal No. ________________________________

Agent’s Name & Code No.
______________________________________________________________________________
Full Name of the Proposer ______________________________________ Age ________________
(IN BLOCK LETTERS)
1. (a) Have you ever had pain in the region (a) __________________________________
of your kidneys?
(b) If yes, give. (b) _________________________________
(i) The number of attacks: i) _________________________________
(ii) The date & duration of the first ii) ________________________________
attack:
iii) _________________________________
(iii) The dates & duration of the
subsequent attacks. iv) __________________________________
(iv)The date & duration of the last

attack.
2. (a) Was the pain colicky in nature or was (a) ___________________________________

it dull and continous?
(b) Was it accompanied by fever? (b) ___________________________________
3. Were attacks accompanied by retention

of or scanty urine, or passage of blood or
stone in urine? If yes, give full
particulars.
4. (a) Were you confined to bed with any or all (a) __________________________________
of the attacks? (b) ____________________________________
(b)How long did such attacks keep you from
work?
5. (a) Was an X-Ray of your kidneys and (a) _________________________________

urinary tract taken?
(b)If yes, state : (b) _______________________________
(i) Whether it was taken with or without i)
an intravenous injection of dye? __________________________________
112
(ii)The dates ii)
(iii)Findings. ______________________________________
iii)
______________________________________
Please submit all X-Ray plates with the radiologists’ reports thereon.
6. Was an operation performed on your

kidneys, ureters or bladder?
If yes, give the dates & state whether a
stone alone was removed or whether the
kidney was removed with the stone.
Please submit the operating surgeon’s
report which should state the reason for
the operation, its nature and findings.
7. Has there been recurrence of pain, colic

or discomfort at any time after the
operation? If yes, give full details.
8. a) Has your urine been examined during

or after the attacks of pain?
If yes, give the dates of the
examinations.
b) Was any blood, pus, albumin casts, or
oxalates, uric acid or urates found in
any such examination?
If yes, give full details.
Please submit reports of the urine
examinations.
9. Give the names and addresses of the

doctors who attended you.
I agree that the foregoing questions and answers shall form part of the proposal for
assurance made by me to the Life Insurance Corporation of India
on________________________________________
113
_____________________________
Date _____________________________ Signature of the Proposer
Signature of Witness : ……………………………….

Occupation : ……………………………………………
Address : ………………………………………………..
114
Musculoskeletal disorders questionnaire –
To be completed by the Attending physician
Full name of applicant:
1 Please give the diagnosis and the results of any relevant

investigations.
2 Please provide details of the frequency and severity of

symptoms and the duration(s) of incapacity including
dates and time off work.
3 How has the condition been treated; is future surgery

planned?
4 Please give details of current symptoms.
5 Have there been any episodes of associated anxiety of

depression? If so, please give details.
Signed
Date
115
Revival of Lapsed Policy Form No 680
PERSONAL STATEMENT REGARDING HEALTH
(Revival of Lapsed Policies on both Medical & Non-Medical basis)
Agent’s Name :
Divl. Office: Branch Office: Policy No
1. Full name of the Life Assured………………………………………………
Address1……………………………………………………………………….
Full Address2………………………………………………………………….
Address………………………………………………………………………...
Address3……………………………………………………………………….
E-mail Address Phone/Mobile No…………………………………………….

Occupation……………………………………………………………………..
Name of Employer………………………………..Length of Service with him………..years
2. Since the date of your Proposal for the

above mentioned Policy:
Answer
'Yes' or 'No'
If 'Yes" give details of ailment such as nature of illness, date of onset,
duration of illness etc………………………………………………………………..
(a) Have you ever suffered from any illness/disease requiring treatment for a
week or more?...........................................................................................................
(b) Did you ever have any operation, accident or injury?........................................
(c) Did you ever undergo ECG, X-Ray, Screening, Blood, Urine or Stool
examination?..............................................................................................................
"If in this form, the answers to the questions and/or signature of the Life Assured are
given in vernacular, then the Life Assured should declare in his own handwriting above his
own signature that all questions were explained to him and that his replies were given after
fully and properly understanding the same."
(1)This declaration should be made by the person filling in the form
Name & Address of the declarant……………………………………………………….
(2) I hereby declare that I have fully explained the above questions to the Life Assured and
I have truthfully recorded the answers given by the Life Assured.
Signature…………………………….
In case the Life Assured is Illiterate:
(2) The thumb impression of the Life Assured 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:
Name & Address of the declarant:…………………………………………………
(2) I hereby declare that I have explained the contents of this form to the Life Assured in
(language) and that I have read out to the Life Assured, the answers to the questions
dictated by the Life Assured and that the Life Assured has affixed his thumb impression to
this form after fully understanding the contents thereof.
116
Signature:…………………………………………
3. Has a proposal or an application for revival of a policy on your life made

to this or any other Office of the Corporation or any Insurer ever been:
(i) Withdrawn or dropped?.......................................................................................
(ii) Accepted with an extra premium or lien?...........................................................
(iii) Deferred or declined?...........................................................................................
(iv) Accepted on terms otherwise than those proposed?............................................
If so, give details:……………………………………………………………………
(b)Is any proposal or an application for revival of a. lapsed
policy on your life under consideration of this or any other
Office of the Corporation?..........................................................................................
If answer is 'Yes' give the (i) Proposal No…………………………………………..
(ii) Policy No……………………………………………………………………….
4. Are you at present in sound health?...............................................

N.B. - For Revivals under Non-medical scheme (Question Nos. 5 & 6)
5. (i) State your height (without shoes) cm……………………….

(ii) Your weight (with thin clothes.) kgs………………………….
6. State below, details of all your policies issued and/or revived under any of the
MEDICAL Scheme of the Corporation:……………………………………….
Divisional Office/ Policy No Sum Assured Status of policy

Unit/ branch office
For Females only:

(i) Have you been menstruating regularly?...............................................
(ii) Have you had any miscarriage/s?........................................................
(iii) Are you pregnant now?......................................................................
(iv) State the date of last menstruation:………………………………….
7. Since the date of your proposal under the above mentioned policy:………………………
(v) State the date of last delivery:……………………………………….
DECLARATION
I ……………do hereby declare that the foregoing statements and answers are true and
complete in every particular, and agree and declare that these statements and this
declaration along with my Proposal for Insurance under the lapsed policy shall be the basis
of the contract of revival of the lapsed policy between me and Life Insurance Corporation of
India, and that If any untrue averment be contained therein, the said contract shall be
absolutely null and void and all moneys which shall have been paid in respect thereof, shall
stand forfeited to the Corporation.
And I further declare that if between the date of this declaration and the date of revival of
the policy (i) any change in any occupation or any adverse circumstances connected with
my financial position or the general health of myself or that of any member of my family
117
occurs or (ii) a Proposal for assurance or any application for revival of a policy on my life
made to any Office of the Corporation is pending or has been withdrawn or dropped,
deferred or declined or accepted at an increased premium or subject to a lien or on terms
other than as proposed, I shall forthwith intimate the same to the Corporation in writing to
reconsider the terms of Revival of the Policy. Any omission on my part to do so shall render
the Revival absolutely null and void and all moneys which shall have been paid in respect
thereof, shall stand forfeited to the Corporation.
Dated at…………….. on the…………… day of ……………(month) 20
Signature of Witness
Name :………………………………….
Occupation :……………………………
& Address :……………………………..
Signature or Thumb impression of the Life Assured
118
Revival of Lapsed Policy Form 700

For a policy on another life except for C.D.A. Plan with deferment period 10 years or ore on
the date of proposal or revival of a Policy. Do not use this form if the policy has vested in
the life assured or has been assigned to the life assured.
Divl. Office:……………………………..
Branch Office:…………………………..
Prop./ Policy No…………………………
Agent’s Name……………………………
Agent’s Code No…………………………
Following questions to be answered by the Proposer
1. Name in Full of the Proposer………………………………………………
( IN BLOCK LETTERS )
Address 1…………………………………………………………………….
Address 2…………………………………………………………………….
Full Address
Address 3……………………………………………………………………..
E-mail Address Phone/Mobile No……………………………………………
2.Name in Full of the Life to be Assured/Life Assured (IN BLOCK LETTERS )
…………………………………………………………………………………..
Occupation………………………………………………………………………
Name of Employer………………………………………………………………
Length of Service with him……………………………………………………..
3. Is this application for
If the answer is ‘YES’ please give the Proposal Number or the Policy Number
(a) Issue of a new Policy? ……………………………………………….
(a) Proposal No………………………………………………………….
(b) Revival of lapsed Policy?....................................................................
(b) Policy No…………………………………………………………….
Following questions to be answered by the Life to be assured / Life Assured
4. Since the date of your above mentioned proposal / since the date of proposal for the
above mentioned policy :………………………………………………………………..
Answer
'Yes' or 'No'
If ‘Yes’ give details of ailment date and duration, doctors consulted.
……………………………………………………………………………………………
……………………………………………………………………………………………
(a) Have you suffered from any illness/disease requiring treatment for a week or more?
(a)…………………………………………………………………………………………..
(b) Did you ever have any operation, accident or injury?
(b)…………………………………………………………………………………..
(c) Did you ever undergo ECG, X-Ray, Screening, Blood , Urine or Stool examination?
(c)……………………………………………………………………………………….
5.(a) Has a proposal or an application for revival of a policy on your life made to this or any
other Office of the Corporation or any Insurer ever been:
(a) Withdrawn or dropped?....................................
119
(b) Deferred or declined?.......................................
(c) Accepted with an extra premium or lien?.................
(d Accepted on terms otherwise than those proposed?..............................
If so, give details:………………………………………………………….
5. (b) Is any proposal or an application for revival of a. lapsed policy on your life under
consideration of this or any other Office of the Corporation?...............................................
If answer is 'Yes' give the following details: ((iii)) P Proolpicoysa Nl No.o .
N.B. Q Nos. 6 & 7 to be replied in case of revival under Non Medical Scheme :
6.(i) State your height (without shoes) cm.
(ii) Your weight (with thin clothes.) kgs
7. State below, details of all your policies issued and/or revived under any of the Non-
Medical Schemes of the
Corporation:
Name of the Divl. Office/Unit
Br. Office Servicing the
Policy
Policy Number Sum Assured Status of the
Policy
8.Are you at present in sound health?
9. Are you a student? If so give particulars such as name of
the institution and course.
10. For females only :
a. Since the date of your above mentioned proposal or policy:
(i) Have you been menstruating regularly?
(ii) Have you had any miscarriage/s?
(iii) Are you pregnant now?
(b) State the date of last menstruation:
(c) State the date of last delivery:
DECLARATION BY THE LIFE TO BE ASSURED/LIFE ASSURED
I do hereby declare that the statements and answers under heading 4 to 10 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.
Dated at……………….. on the…………… day of (month) 20
Name
Occupation & Address
Signature or thumb impression of the Life to be
Assured/Life Assured
Name
I do hereby declare that the foregoing statements and answers are true and complete in
every particulars
(if the life to be assured/life assured is under 18 years)
DECLARATION BY THE PROPOSER
I, ( name of Proposer )…………………………………………………………………
do hereby declare that the statements and answers under heading 1 to 3 are true and
complete in every particular and I do hereby agree and declare that these statements and this
declaration together with statements and answers under heading 4 to 10 made by the *life
assured/ life to be assured and relative declaration thereto shall be the basis of contract of
*assurance/revival of the policy, between me and Life Insurance Corporation of India, and
120
that if any untrue averment be contained therein, the said contract shall be null and void and
all moneys which shall have been paid in respect thereof, shall stand forfeited to the
Corporation.
( *Delete words not applicable )
** And I further declare that if between the date of this declaration and date of revival of
this policy, (i) any change in the occupation of the life assured or any adverse circumstances
connected with my financial position or general health of the life assured or that of any
member of his family occurs or (ii) a Proposal for assurance or any application for revival
of a policy on the life of the life assured made to any Office of the Corporation has been
withdrawn or dropped, deferred or declined or accepted with an increased premium or
subject to a lien or on terms other than as proposed, I shall forthwith intimate the same to
the Corporation in writing to reconsider the terms of acceptance . Any omission on my part
to do so shall render this Assurance invalid and all moneys which shall have been paid in
respect thereof, shall stand forfeited to the Corporation.
(** Not Applicable in case of an application for issue of a new policy.)
Dated at on the day of (month) 20
Name
Signature or thumb impression of the Life to
be Assured/ Life Assured
N.B.
If in this form, the answers to the questions and/or signature(s) of the Proposer/Life
Assured/Life to be assured are/is in vernacular then the Proposer/Life Assured/Life to be
assured should declare in their/ his/her own handwriting above his/her own signature that
all questions were explained to him/her and that his/her replies were given after fully
understanding the same.
In case the proposer/Life assured/Life to be assured is illiterate:
Name & Address of the declarant
(1) I hereby declare that I have fully explained the above questions to the proposer/Life
Assured/Life to be assured and I have truthfully recorded the answers given by the Proposer
/ Life Assured/ Life to be assured.
Signature
(2) This thumb impression of the Proposer/Life Assured/Life to be assured
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:
(2) I hereby declare that I have explained the contents of this form to the proposer/ Life
Assured/ Life to be assured in ……………..(language) and that I have read out to the
Proposer / Life Assured/ Life to be assured ,the answers to the questions dictated by the
Proposer/Life Assured / Life to be assured and
that the Proposer / Life Assured / Life to be assured has affixed his thumb impression to this
form after fully understanding' the contents thereof.
Signature
121
Revival of Lapsed Policy Form 720

For a policy on another life under C.D.A. Plan with deferment period 10 years or
more on the date of proposal or revival of policy.
Divl. Office:
Branch Office:
Prop./Policy No
Agent’s Name
Agent’s Code No.
1. Full name of the Proposer
(IN BLOCK LETTERS )
Address1
Address 2
Full Address
Address 3
E-mail Address
Phone/ Mobile No
2. Full name of the Life Assured / Life to be assured
(IN BLOCK LETTERS)
Occupation
Name of the employer
Length of service with him
3. Is this application for
If the answer is ‘YES’ please give the proposal number
Or policy number.
122
(a)Issue of a new policy ? Proposal No :
(b) Revival of lapsed policy ? Policy No:
4. Since the date of your above mentioned
proposal / since the date of proposal for the
above mentioned policy:
Answer “Yes” or “No”
If “Yes” give details of ailment, date and duration
Doctors consulted
(a) Has he / she suffered from any illness / disease
Requiring treatment for a week or more?
(b) Did he /she have any operation, accident or injury?
(c) Did he/ she undergo ECG, X-ray, screening, blood,
Urine or stool examination ?
5(a) Has a proposal or an application for revival of
a policy on hi /her life made to this or any other office
of the Corporation or nay insurer ever been
(i) withdrawn or dropped?
(ii) accepted with an extra premium or lien?
(iii) deferred or declined?
(iv) accepted on terms otherwise than those proposed?
If so, give details:
5(b) Is any proposal or any application for revival of a lapsed
policy on his / her life under consideration of this or any other
Office of the Corporation ?
Yes / No.
(i)Proposal No.
If answer is “Yes” give the following details :
(ii) Policy No
6. Is he / she now in sound health ?
7. Is he / she a student ? If so, in which standard?
DECLARATION BY THE PROPOSER

I, ( name of Proposer ) do hereby declare that the foregoing statements and answers are true
in every particular, and agree and declare that these statements and this declaration along
with my Proposal for Insurance shall be the basis of the contract of *assurance/ revival of
the lapsed policy, between me and Life Insurance Corporation of India, and that if any
untrue averment be contained therein, the said contract shall be absolutely null and void and
all moneys which shall have been paid in respect thereof, shall stand forfeited to the
Corporation.
( * Delete words not applicable )
** And I further declare that if between the date of this declaration and the date of revival
of the policy (i) any change in the occupation of the life assured or any adverse
circumstances connected with the financial position or general health of the life assured or
that of any member of his family occurs or
(ii) a Proposal for assurance or an application for revival of a policy on the life of the life
assured made to any Office of the Corporation has been withdrawn or dropped, deferred or
declined or accepted with an increased premium or subject to a lien or on terms other than
as proposed, I shall forthwith intimate the same to the Corporation in writing to reconsider
the terms of acceptance . Any omission on my part to do so shall render this Assurance
invalid and all moneys which shall have been paid in respect thereof, shall stand forfeited to
the Corporation.
(** Not Applicable in case of an application for issue of a new policy.)
123
Dated at…………. on the…………… day of (month)………….. 20
Name
Signature or thumb impression of the Proposer.
If in this form, the answers to the questions and/or signature of the Proposer are given in
vernacular, then the Proposer should declare in his own handwriting above his own
signature that all questions were explained to him and that his replies were given after fully
and properly understanding the same.
(1) 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.
Signature
In case, the Proposer is Illiterate:
(2)The thumb impression of the Proposer 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:
Name & Address Of the declarant
(2) I hereby declare that I have explained the contents of this form to the Proposer in
………………….. (language) and that I have read out to the Proposer, the answers to the
questions dictated by the Proposer and that the Proposer has affixed his thumb impression
to this form after fully understanding' the contents thereof.
Signature
124
Pleurisy Questionnaire Form No 3337
Proposal No…………………..
Full Name of the proposer………………….. Age…………………..
1. Date of diagnosis
2. Details of illness prior to diagnosis of
pleurisy, if any
3. Date of complete recovery
4. Date of joining full time duties
5. Whether the pleurisy was dry, or with
effusion or purulent
6. Whether there was any suspicion of
tubercular lesion in the lungs?
7. What was the nature of treatment? Please
give details of treatment (Drugs and
Surgical treatment)
8. Whether any treatment was continued
after recovery and/ or joining duties? If so,
givr particulars
9. Dates of all X-Rays taken. Reports and
plates should be enclosed
10. Dates of Blood, E.S.R. and sputum
reports done. Reports should be enclosed.
11. Weight : a) before illness a)
b) during illness b)
c) after complete recovery c)
12. Names and addresses of Medical
Attendants & Sanatorium
13. Are you undergoing or have you
undergone any check ups after complete
recovery. If so, give details
It is hereby declared that the particulars given above are true and complete and together the
life assurance proposal dated…………………..shall be the basis of the contract of
assurance.
Dated at…………………..on the ……………………day of …………………….20
Witness :
………………………………. ………………………………
125
Signature of the Medical Examiner Signature of the life to be Assured
N.B:- This form should be accompanied by all X-Ray plates together with all other hospital
discharge certificates.
126
Renal Transplantation Questionnaire
Confidential Report of the Transplantation Centre
Particulars of the patient :

Name: First Name:
…………………………….. ………………………………………
Date of birth: Residence:
………………….. …………………………………………
Cause of end-stage renal disease

Primary kidney disease : which ? ………………………………….
Systemic disease: which? ………………………………….
Other cause: which ? ………………………………….

Details of renal transplantation
Which kind of transplantation ? synergic………………. Allogenic……………….
How many transplantations? One………… two…………three or more…………..
Date of last transplantation :
Has dialysis become necessary since transplantation?

……………… yes ………………………no
Information on rejection reactions
How many acute rejection crises has the patient sustained?
…………..none ………………1 to 3 ……………….. 4 and more
Date of last crisis :
Are there any signs of chronic rejection?
……………. Yes ………………. No …………… not known
Current renal function

Judgement of prognosis on the basis of the check- ups over the last six months
127
……… very good ……….. good …………. reduced ……….. stable
………improving ………… deteriorating
Findings of the last examination

Test Date Result Normal Value
(where necessary)
Blood pressure
Protein in the urine
Urinary sediment
Plasma Creatinine
Haemoglobin and /
or
Haematocrit
HIV Test
Other findings
Comments:
Maintenance – Immunosuppression
Is immunosuppression continued ?
…………. Yes ……………. No Why not?
Which immunosuppressive agents are taken presently by the patient ?
…………… azathioprine …………… prednisone : dosage ?
…………… cyclosporine ……………. Others: which?
Side – effects of immunosuppression
Have any serious side- effects occurred or are still present ?
…………… yes ………….. no
Which ? When ? Successfully treated ? Persisting or Progressive?
…………… Infections
…………… Tumours
…………… Cyclosporin- nephropathy

…………….. others : which ?
Check – ups
By whom are the check – ups carried out ?
…………. Transplantation centre : Date of last check- up ?
128
…………. Nephrologic unit of a peripheral hospital : Date of last check- up?
…………. Nephrologist experienced with patients having undergone renal

transplantation : Date of last Check- up?
………….. Others :
Date of last check – up?
Comments
Rubber stamp of Transplantation centre
Place and date : Signature :
Form No 3336
Tuberculosis Questionnaire
Proposal No…………………
Full Name of the proposer…………………………Age……………………..
1. Date of diagnosis of Tuberculosis

2. Details of illness prior to diagnosis of
129
T.B., if any
3. Date of complete recovery from
Tuberculosis
4. Date of joining full time duties
5. What was the nature of treatment?
(a) Rest
(b) Medication? Type and when
discontinued
(c ) Pneumothorax or
Pneumoperitoneum. When discontinued?
(d) Surgery? Type and date, Hospital or
operating surgeon’s certificate should be
enclosed
6. Date of all X-Rays taken. Report and
plates should be enclosed.
7. Dates of all Blood , E.S.R and Sputum
report done. Reports should be enclosed.
8. Weight (a) before illness (a)
(b) during illness (b)
(c ) after complete recovery (c )
9. Names and addresses of Medical
Attendants and Sanatorium
10. Whether any treatment was continued
after recovery/ or joining duties ? If so,
give particulars
11. Are you undergoing or have you
undergone any check – ups after complete
recovery? If so give details
It is hereby declared that the particulars given above are true and complete and together
with the Life Assurance proposal dated…………………………………..
shall be the basis of the contract of assurance.
Dated at…………………………….on the …………………….day of ………….20
Witness:
…………………………. ……………………
Signature of the Medical examiner Signature of the life assured
N.B:- This form should be accompanied by all X-Ray plates together with all other reports
and hospital discharge certificates.
130
TUMOUR QUESTIONNAIRE ---ATTENDING PHYSICIAN
Full name of applicant:
In order to make an equitable underwriting assessment it is necessary, for many

tumours, to have detailed information as requested below. You may find it
more convenient to send copies of the tumour pathology reports and the results
of follow-up reviews and investigations.
1 When was the initial diagnosis made?
131
2 What was the site or organ involved?
3 What was the histological type and grade of tumour? If in

situ only, please confirm that there was no stromal
infiltration.
4i Please provide details of the staging of the tumour:

a Was it completely localised to the tissue or organ of YES / NO
origin?
b Was there invasion of adjacent tissues. If YES, please YES / NO
state which.
c Was there involvement of regional lymph nodes? If YES, YES / NO

please state site(s) and number of nodes involved.
d Were there distant metastases? If YES, please state where. YES / NO
ii For breast cancer, please indicate the size of the primary

tumour:
a) < 2cm
b) 2 - 5 cm
c) > 5cm
iii For the tumours below, please give the appropriate

classification:
Bladder carcinoma - Marshall / TNM

Colonic carcinoma - Dukes'
Invasive cervical carcinoma - FIGO / TNM
Skin melanoma - Clark level / tumour thickness
132
5 Please give details of the type(s) of treatment:
a Surgery. Please give date and details of operation. YES / NO
b Irradiation. Please give dates and details of fields treated. YES / NO
c Chemotherapy. Please give dates and details of drugs YES / NO

used.
d Endocrine therapy. Please give dates and details of agents YES / NO

used.
6 Has there been any recurrence or relapse? If so, please

give details of:
a Date(s)
b Site(s)
c Treatment
7 Please provide the name and address of the

consultant/hospital your patient attends for follow-up, and
the date of the last attendance.
8 As far as it is possible to tell, has the disease been totally

eradicated?
Signed
Date
133
134
OCCUPATION QUESTIONNAIRES
Annexure II
GENERAL OCCUPATION QUESTIONNAIRE

Proposal No_____________________ Form No. LIC03 - 500
Name of the Proposer______________________________________________
Please state:
a. Full name of the Employer
(please do not use abbreviations)
b. Department in which you work
c. Your designation or occupation
d. Full details of the nature of your duties
e. If you are supervisor, nature or work done
under your supervision
Please answer ticked Item No/s below:
1. Construction workers
a. Are you engaged in scaffolder / steel erector
activity
b. Are you a painter – exterior
2. Drivers
a. Do you drive public carriers (goods /
passenger vehicles)?
b. Do you hold national driving permit?
135
3. Manufacturing
a. Acids
Are you a lead burner working in vats or
chambers?
b. Explosive & Ammunition –

Are you employed in salvage and
reconditioning department?
4. Tunnelling
a. Are you air compressor operator, Civil
engineer, Engineering geologist, Structural
engineer?
b. Are you dumper shovel driver / Foreman
(above ground) / Mechanical shovel driver /
Winch driver?
c. Are you conveyor operator / Foreman (below
ground ) / Manhole maker / Power loader
operator / Roof bolter / Timberman?
d. Are you Borer / Driller / Tunnel miner (no
explosives) / Tunneller (no explosives)?
e. Are you Shotfirer / Tunnel miner (using
explosives) / Tunnel miner's labourer /
Tunneller (using explosives)?
5. Mining Industry
a. The type of mine
b. Whether you work underground and the
average number of hours spent underground
per week?
c. Are you an underground rescue worker?
d. Are you a short firer in colliery?
6. Motor cycle sport -Circuit racing

a. Do you take part in motor cycle circuit racing
– (closed, restricted or national events)
b. What is the engine capacity of the motor
cycle?
c. Number of events per annum
d. Do you take part in international events?
7. Oil & Natural Gas Industry

a. Are you based offshore or do you expect to
be based offshore in future?
b. Do your duties involve underwater work?
c. Do your duties involve working at heights?
d. Do you ever travel to and from rigs by
helicopter?
e. Can your occupation be described as:
Drilling assistant, Fire fighter, connection
mechanic, crane operator, Top-man, Rigman,
Derrickman, Roughneck, roustabout (not
136
handling explosives)?
8. Sewers & Sewage Disposals

Are you a labourer, Cleaner, inspector of
underground duties?
DECLARATION
I ___________________________________________ do hereby declare that the foregoing

statements and answers are true in every particular and agree and declare that these
statements and this declaration along with my Proposal for Insurance and the Declaration
relative thereto shall form the basis of the contract between me and the Life Insurance
Corporation of India and that if any untrue averment be contained therein the said contract
shall be absolutely null and void and moneys which shall have been paid in respect thereof
shall stand forfeited to the Corporation.
Dated at _____________on the _________day of _____________200
Signature of Witness__________________
Occupation
Address Signature of the Life to be assured
In case the Proposer is illiterate:
1. This declaration should be made by the person filling in the form:
I hereby declare that I have fully explained the above questions to the proposer & I have
truthfully recorded the answers given by the proposer.
Address of the Declarant Signature

______________________
2. The thumb impression of the proposer should be attested by a person of standing whose
identity can be easily established, but unconnected with the Corporation and this declaration
should be made by him:
I hereby declare that I have explained the contents of this form to the proposer in
__________(language) and that I have read out to the proposer the answers to the questions
dictated by the proposer and that the proposer has affixed his thumb impression to this form
after fully understanding the contents thereof.
137
_____________________
ARMY PERSONNEL QUESTIONNAIRE
Proposal No._______________ Form No. LIC03 - 501
Name of the Life to be assured in full_________________________________
1. Give particulars regarding the branch of the Defence

Forces, Regiment, etc. to which you belong and your
present rank.
2. a. Are you, at present, engaged in

i. any flying duties as a Pilot or member of
aircrew or other duties requiring you to
remain aboard an aircraft otherwise than as
a passenger for the purposes of transport
ii. duties as a Paratrooper
iii. duties as a Glider Pilot
iv. duties as a member of aviation operating
personnel or ground personnel
b. Were you engaged in the past in any of the duties

mentioned under (a) above, and if so, are you likely
or liable to return to the same in future?
c. Have you undergone or are you now undergoing

training for any of the duties mentioned under (a)
above?
d. Have you, under the terms and conditions of your

service, any special liability to engage in Aviation,
Gliding, Parachuting, Bomb disposal, Special
Service group, mine laying, etc.
N.B.: The liability referred to herein is not the general liability

imposed on all Defence Service Personnel in terms of which
138
they can be called upon to take up any type of work in any of
the Defence Services.
3. Are you a member of any Flying or Gliding Club? If

so, state:
i. whether you are undergoing training in
flying, or gliding or whether you have
completed such training?
ii. The number of flights made per annum
N. B. In addition to the duties to be performed by you as a

member of Armed Services, in case your duties require you to
engage yourself in any other hazardous duties such as in
a. Manufacture and / or reconditioning of Ammunitions,

b. construction work requiring use of explosives and / or
compressed air,
c. welding and spray painting,
d handling Electrical equipments carrying a voltage of &
over and / or working at heights,
e handling or remaining exposed to fumes, gas, acids or
other chemicals,
f driving trucks or lorries or,
g any other hazardous occupation,
A separate Occupational Query Form (Form No. LIC03 - 500)

should also be completed in addition to completing this form.
DECLARATION

Occupation
139

______________________
140
AVIATION (ARMED SERVICES) QUESTIONNAIRE
Proposal No._________________ Form No. LIC03 - 502
Name of the Life to be assured__________________________________________
1. State
i. Whether you are in Army, Navy or Air Force
ii. Branch of the Service to which you belong
iii. Your Rank in Service
2. If you belong to a Flying Branch, or Unit, state in what capacity do

you fly – pilot, navigator, instructor, etc.
3. If you are a qualified pilot, state
a. When and where did you learn to fly?

b. The date on which you qualified as a pilot?
c. The date on which you made first solo flight
d. Which aircraft do you fly?
e. Number of hours of solo flying done during the last 12
months
f. Number of hours of solo flying done to date
g. Are you under orders to fly a different type of aircraft
4. State whether you have ever been or have any prospect or intention
of being involved in
a. test flights on proto-type models

b. racing for establishing flying records or aerobatics
c. exhibitions or display flying
5. If you belong to a Ground Duties Branch or Unit, state:
a. the nature of your duties

b. whether you are required to fly in a capacity involving duties
aboard an aircraft while in flight
c. whether you have undergone training as a pilot or other member
of flying crew and if not, whether you intend to undergo such
training
6. If answer to Question 5(b) is “Yes”, state:
141
a. The number of hours flown in a capacity involving duties aboard
an aircraft while in flight
i. during the current calendar year to date
ii. during the last full calendar year
iii. during the previous to last full calendar year
b. Whether you expect that the extent of flying to be done by you in

future would differ from that done in the past and if so, explain
how
DECLARATION

Occupation

______________________
142
AVIATION (CIVIL) QUESTIONNAIRE
Name of the Life to be assured__________________________________________
143
1. State
i. Whether you are in Army, Navy or Air Force
ii. Branch of the Service to which you belong
iii. Your Rank in Service
2. If you belong to a Flying Branch, or Unit, state in what capacity do

you fly – pilot, navigator, instructor, etc.
3. If you are a qualified pilot, state
a. When and where did you learn to fly?

b. The date on which you qualified as a pilot?
c. The date on which you made first solo flight
d. Which aircraft do you fly?
e. Number of hours of solo flying done during the last 12 months
f. Number of hours of solo flying done to date
g. Are you under orders to fly a different type of aircraft
4. State whether you have ever been or have any prospect or intention
of being involved in
a. test flights on proto-type models

b. racing for establishing flying records or aerobatics
c. exhibitions or display flying
5. If you belong to a Ground Duties Branch or Unit, state:
a. the nature of your duties

b. whether you are required to fly in a capacity involving duties
c. whether you have undergone training as a pilot or other
member of flying crew and if not, whether you intend to undergo
such training
6. If answer to Question 5(b) is “Yes”, state:
a. The number of hours flown in a capacity involving duties

i. during the current calendar year to date
ii. during the last full calendar year
iii. during the previous to last full calendar year
b. Whether you expect that the extent of flying to be done by you

in future would differ from that done in the past and if so, explain
how
144
DECLARATION

Occupation

______________________
CIVIL GLIDING QUESTIONNAIRE
Name of the Proposer_________________________________________
145
i. Name of the gliding club of which you are
a member
ii. Whether you are an Instructor or an

ordinary member of the Club?
iii. Have you ever been engaged in the past or

do you intend to engage in future in
advance competition flying?
iv. Have you undergone training as a pilot or

other member of aircrew of a powered air-
craft or do you intend to undergo such
training?
DECLARATION

Occupation

______________________
146
NAVY PERSONNEL QUESTIONNAIRE
Proposal No_______________________ Form No. LIC03 - 505
Name of the Life to be assured_____________________________________________
1. Give particulars regarding the branch of the Naval Forces, etc. to

which you belong and your present rank?
147
2. a. Are you at present engaged in:
a. Any flying duties as a pilot or member of aircrew or

other duties requiring you to remain on board an aircraft
otherwise than as a passenger for the purpose of
transport
b. Duties as a paratrooper
c. Duties as a Glider pilot or
d. Duties as a member of aviation operating personnel or
ground personnel
b. Were you engaged in the past in any of the duties mentioned

under (A) above, and if so, are you likely or liable to return to
the same in future?
c. Have you undergone or are you now undergoing training for

any of the duties mentioned under (A) above?
d. Have you, under the terms and conditions, of your service, any
special liability to engage in Aviation, Gliding or Parachuting?
N.B. - The liability referred to herein is not the general liability

imposed on all Defence Service Personnel in terms of which they can
be called upon to make up any type of work in any of the Defence
Services.
3. Are you a member of any Flying or Gliding Club? If so, state:
a. whether you are undergoing training in flying or gliding or

whether you have completed such training?
b. the number of flights made per annum
4. a. Have you ever been or do you intend to or are you liable or

likely to be engaged to do any work in a submarine, Mine-
layer or Minesweeper and if so, in what capacity?
b. Have you received any training or are you liable or likely to
receive any training to work in a submarine, mine-layer or
Mine-sweeper? If so, give details
5. a. Have you ever been required to or do you intend or are you

liable or likely to do diving in the course of your duties?
b. State the maximum depth up to which you have dived or have

been trained to dive and number of dives undertaken during
the last 12 months
DECLARATION
148
Occupation

______________________
149
DIVING (ARMED SERVICES AND COMMERCIAL) QUESTIONNAIRE
Proposal No___________________ Form No. LIC03 - 506
Name of Life to be assured____________________________________________
1. Do you dive professionally / as an amateur /

for pleasure?
2. For how long have you been engaged in

diving?
3. Did you undergo special training for diving?

If yes, please state
Name and Address of the Training Institute
Your qualification / grade
4. Are you a member of any Diving Club?

If yes, state
Name and address of the Club
5. Who is your current employer?
6. Do you use any equipment for diving?
150
If yes, state
Make & Model of equipment
7. Where do you normally dive?

Countries / states
Whether in deep sea, coastal waters, rivers,
lakes
8. Please describe your precise duties whilst

diving?
9. Do you ever use explosives?
10. How many dives do you make per month?
11. Depth of dives

Maximum depth to which you dive
Average depth of dives
12. Length of dives

Maximum length of dive
Average length of dive
13. Do you engage in saturation diving?
14. Do you dive as a part of a team or solo?

If part of a team –
How many divers are in the team?
If solo – How many solo dives do you make
per month?
15. Have you ever suffered from any complaints

during or after diving or had an accident
while diving? If yes,
a. On what date
b. Nature and duration of symptoms
c. Nature and duration of treatment
d. Any sequelae
16. Name and address of the Institution /

Hospital / Doctor who treated you
17. Do you undergo regular medical check-up?

If Yes,
Name and address of the Institution /
Hospital / doctor where these check-up
are conducted
18. Were you ever advised to abstain from
151
diving as a result of medical check ups?
If yes, give details
DECLARATION

Occupation


______________________
152
MERCHANT MARINE QUESTIONNAIRE
Name of the Proposer______________________________________________
1. On what type of vessel do you normally

serve?
Cargo, passenger, container, etc
2. In what country is the vessel registered?
3. What is the gross tonnage of the vessel?
4. What type of cargo does the vessel carry?
5. What is your specific job title?
6. What are your precise duties?
7. In what areas does the vessel operate?

If this includes the Middle East area, Please
give full details
DECLARATION
153
Occupation

______________________
154
FINANCIAL QUESTIONNAIRES
155
F3251/F5122 (Rev.89)
LIFE INSURANCE COPORATION OF INDIA

(Established by the Life Insurance Corporation Act 1956)
_______________DIVISION
Confidential Report of the : Agent authorised to complete F.No.3251/5122

Development Officer/ABM(S) /BM / Sr.B.M./A.D.M ( S) / M.M
INSTRUCTIONS:
_____________
1.Before completion of the report the reporting official should satisfy himself regarding the
identity of the proposer. He should meet him , preferably at his residence before
completing the report. The reporting official should make detailed independent enquiries
about the life to be assured's health and habits in addition to reporting on his financial
status. It should be borne in mind that the decision of the LIC will be largely influenced by
this report.
2. This report must be completed immediately after the enquiries are made:
_____________________________________________________________
_1. Full Name of the proposer............................Age.... years.
Full Name of the life to be assured…………………………………………Age...... years.

Occupation:Exacat nature of duties/Business....................................Sum proposed.........
Full Address.....................................................
..........................................................………………
2. a. Are you satisfied about the identity a...................................

of the life proposed ?
b. By whom were you introduced to the Proposer/Life to be insured?
……………………………………………………………………………………………….
c. Give marks of his/her identification
……………………………………………………………………………………………….
d. Total previous insurance in force-Sum Assured...............................

e. Do you feel that total insurance
added to the present proposal is
reasonable in relation to income?
e..........................................................................................................................................
156
_________________________________________________________________________
_3. What is you assessment about the general health of the Life proposed
…………………………………………………………………………………………………………………………………………………………………
…………………………….
4. What is proposers yearly income from

(i) Employment i. Rs…………………………per annum
(ii) Business or professsion ii. Rs..........per annum
(iii) Other sources(to be specified) iii. Rs...…......per annum
(iv) H U F if any iv. Rs..........per annum
(v) State income of the life to be

assured if assured is different
from the proposer. v. Rs..........per annum
(vi) State which document relating

to income were verified.
Remarks such as told by party/agent
Etc” will not be accepted.
vi………………………………………………………….
Give detailed and accurate information about the nature & source of income.
(vii) a. Is he/she Income-tax Assessee? vii.a.Yes /No
b. What is the I.Tax P.A No. b.P.A.No.

GIR No. c. GIR No.
(viii) Are other members of the family viii...................

insured?
5. Does the life proposed look older ?

a. if so, by how many years? a...................................
b. what is the educational

qualification of the life
to be assured? b.....................................
c. What is the general state of

health of the life to be assured? c. ………………………
d. Is his general appearance healthy? d.......................................
e. Has he any physical deformity ,impaired sight or hearing, amputation of limb(s) mental
backwardness or any other impairment?
157
………………………………………………………………………………………………
………………………………………………………………………………………………
f. Does your enquiry indicate of his having any illness or injury or
undergone any operation or hopitalisation or medical investigation in the past ? If
so, give details…………………………………………………………………….
…………………………………………………………………………………….
h. Is there anything in the Life to be Assured's occupation, financial social position,

personal habits or any circumstances which might add to the risk?
…………………………………………………………………………………..
……………………………………………………………………………………
6. Are you satisfied that no previous
Policy of the proposer/Life assured
Has lapsed within last 3 years?
Question No.7 to be answered if the proposal is under Non-medical scheme.
7. Give below weight and physical

measurements:
See note below:
i. Exact height(without shoes) i………………………………………cms
ii. Exact weight (with thin clothes on) ii…………………………………… …kgs
iii.Girth of abdomen at level of navel iii………………………………………cms
iv.Girth of Chest at nipple on

a.Expiration a………………………………… cms
b.inspiration b………………………………….cms
_________________________________________________________________________
NOTE: Height, Weight and Girths of Chest and Abdomen should be found by measurement
only.
_________________________________________________________________________
_______
7. a. Was the proponent ever prosecuted

or are there any prosecutions against him pending? a....................................................
b. Do you consider the acceptance of the

proposal is in order and recommend it as such?
b………………………………………….
I hereby declare that the foregoing statements are true and correct to the best of my
knowledge and belief.
158
Signature
Place:...........................
Date:...............………….......... Name (Block Letters)..................................................

Designation..............................
Address.....................................
............................................................
Agency Code No. and Club Membership, if

any…………………………………………………………………………
CERTIFICATE
It is certified that the Agent Shri/Smt..............................
Code No............... is authorized to fill up this form.
HOD / SALES.
LIFE INSURANCE CORPORATION OF INDIA_______________Division
AGRICULTURAL INCOME CERTIFICATE
Date:
Branch :
Proposal No :
159
Name :
Name & Address of the person in whose name :

the property stands
Name of the village :
Name of the Taluk :
SF Nos. :
Extent of the land and :

Nature of Land (Dry/Wet) :
Market value of the lands owned by the :

Applicant :
Nature of crops grown :
Annual Income Year-wise (Gross and Net Income separately) during each of the last 3
financial years.
Year ending Year ending Year ending
Rs. Rs. Rs.
Gross
Net
Date of Office Seal Signature of Tahsildar
NOTE:
This certificate should be signed by Tahsildar and should bear the seal of the Issuing
Officer and the date of Issue.
160
CHARTERED ACCOUNTANT’S CERTIFICATE
1. Name of the proposer

2. Occupation
3. PAN or GIR Number
4. If the Number in 3 is not available
reasons for the same.
5. Gross Income particulars before Tax

for the last three years (Please give
detailed and accurate information about
the nature of source of income)
Assessment Assessment Assessment
161
Year Year Year
a) Employment
b) Business or Profession
c) Agriculture
d) Investment
e) Property
f) Any other source
Total:
Details of Advance Tax paid for the Current Year Date & Amount Remitted
I certify that Shri / Smt____________________________ is my client and the abovc
information is based on the IT returns filed in respect of my client for the concerned years.
…………………………………………….
Signature of the Chartered Accountant

With Seal & Registration Number
I certify that Shri / Smt is my Chartered Acoountant
……………………………………………..
EMPLOYER-EMPLOYEE SCHEME QUESTIONNAIRE
1. Name of the Employer

2. What is the object of the
insurance contract
3. How many employees are
working in your unit
4. (a) Name of the employee
being covered
(b) His designation /
occupation
( c) Nature of duties
assigned
(d) His annual income
5. Who will be the person
authorized by the employer
to sign the proposal on
162
behalf of the employer
6. Do you wish to impose
any restrictions / conditions
in respect of surrender,
loans etc by the employer
after you assign in favour of
the employee.
7. Are you agreeable to
abide by the conditions of
acceptance which shall rest
solely with the LIC of India
I agree that I will assign the policy in favour of the above employee and the declaration
made by me will for a part of the Insurance contract being entered into in respect of the
employee of mine
Place: Signature and seal of the employer /

Authorised representative with designation
Date:
163
Female Life – Category I Addendum to Proposal

(To be filled in by the female proponent who is employed in institution where NMS is not
applicable)
1. Name of the Life to be Assured :
2 Name of present employer :
Year of Establishment :
Address & Telephone No. :
3. Name of previous employer, if any :
address & telephone no. :
4. Date of joining :
5. Salary per month :
6. Nature of job :
7. Evidence of employment :
(attach zerox duly signed by the person)
a. salary slip :
b. Identity card :
c. ESIS Card :
d. Employer’s Certificate :
e. Copy of appointment letter :
f. Any other evidence (to be specific) :
DECLARATION
I, Mr/Mrs/Ms……………………………………………. Hereby declare that the foregoing

statements are true and correct and shll form part of the proposal form for insurance on my
life.
Dated this day of 200 .
(Signature of the proposer)
164
Witnessed by:
1. Signature of agent
2. Signature of Development Officer.
165
_______________DIVISION.
FORMAT OF SPECIAL M H R BY THE DEV. OFFICER IN RESPECT OF PROPOSAL

ON THE LIVES OF WIDOWS – FALLING UNDER CATEGORY III LADY LIVES.
Propl No.______________ Name______________________SUC___________________
1. Whether she is whole time employee and/or

Engaged in the business.
2. Exact nature of duties of the life proposed

And details of business etc.
3. How many hours per day she devotes to work
4. Names of all children and their ages.
5. If standard age proof is not being submitted,

Reasons for the same.
6. Whether the Dev, Officer has visited the place

Of work of the life proposed and he is satisfied
That she is having earned income.
Signature of the Dev. Officer
Name :
Code No:
No, of years of standing:
This is to be given in addition to Form No. 3251 (Revused).
166
Annexure 'A'
Addendum to Proposal
(To be completed where the policy is desired to be financed through H.U.F. Funds. Please
refer to Question No.5 of the Proposal form)
1. What is the object of this assurance? Is it to be financed from out of Hindu Undivided
Family Funds? 1.
(Please see Note below)
2. Pease state the full Name and Address of the Karta 2……………...
of H.U.F.
3. Please state the names & ages of the present 3.(i)-------aged-------
Members/Co-parcenars in the HUF (ii)------ aged--------
(iii)------aged--------
Signed at---------------------this--------------------------day of-------------------------

---------------------200
Witness:
Signature……………………………………………………
Full Name :.................................. ...................
Occupation : .................................... ... ...........
Address :......... `
........................................................................ (Signature of the proposer)
Witness:
Signature: .....................,
Full Name: .......................................... I agree to issue of policy and payment of
premium as proposed
Occupation: ..........................................
Address:…………………………….
………………………………
(Signature of karta HUF)
Note: If this policy is proposed for the benefit of HUF so as to form a part of HUF Asset
and premiums under the policy are to be paid from out of HUF funds, the policy
will belong to the HUF and in consequence the life assured will not be entitled to
make an assignment or nomination under the policy and will not be entitled to draw
any loan thereunder or surrender the same.
167
```
Annexure 'B'
168
KEYMAN QUESTIONNAIRE
1) Name of the Employer
2) Name of the keyman and

his date of birth
3) (a) Status / Occupation of keyman (a)
(b) Give full details of the keyman’s duties (b)
4) His academic & Professional

Qualification :
What Special Knowledge / expertise does

Keyman possess or why the company
Is so dependent on him?
5) What basis has been used to arrive at the
Sum proposed ?
6) What is the justification for the type
of policy chosen ?
7) State the Employer’s trade turnover Year 20 20 20
And gross /net profit over the last -----------------------------------------
Three years Turnover
-----------------------------------------
Gross Profit
-----------------------------------------
Net Profit
8) What is the realistic , immediate

and future prospects of the
employee
9) Give details of the keyman’s 20- 20- 20- 20- 20-
Salary (including commission -------------------------------------------------
Payments / profit sharing etc.) -------------------------------------------------
Bonus, earned by him during the -------------------------------------------------
last 3 to 5 years -------------------------------------------------
10) If the keyman or any member of his Keyman: …………………..

Family, is a shareholder, what is the
Holding in relation to the total issued Family Members……………
Capital? Specify:………………………
169
11) What are the details of the Keyman’s
Service Agreement?
12) Has the Board authorized the purchase

of policy?
If so, attach the original copy of Board
Resolution,
13) What is the normal retirement date of
the Keyman
14) Does the company hold or intend to effect
Keyman Insurance policies on the lives of
any other key-personnel ? If so, give details
15) Whether the above employee is also
Considered as keyman in other company?
If so, details thereof.
16) What permanent Health or other sickness
Insurance arrangements have been / will
Be made for the keyman.
Place :
Date : Signed…………………………
Official authorized to sign on

behalf of the Employer.
170
DRAFT OF RESOLUTION TO BE PASSED BY COMPANY BOARD FOR KEYMAN

INSURANCE
Copy of the resolution passed in the meeting of the Board of Directors of Directors of
____________________________Ltd. Held on______________.
Resolved that the Company do take Keyman Insurance cover in the year______________in
respect of Shri / Smt / Kum_________________________(Designation) of this Company
for Rs______________with all profits, bonuses and other benefits of _____________years,
the premiums of which will be paid by the Company. This policy shall be taken from the
Life Insurance Corporation of India for a term of ____________years , the premiums of
which will be paid by the Company to safeguard the company from probable losses in the
event of his / her demise / exit from the Company.
Further resolved that Shri / Smt. / Kum.________________________(Designation)

of the Company be and is authorized to negotiate the terms and conditions with Life
Insurance Corporation of India in this behalf and sign all the papers and documents
including proposal papers , required by LIC in this behalf.
Certified true copy
For M/S ______________________________
Signature______________________________
Designation____________________________
Dated :
Place: Seal of the Company
171
ADDENDUM TO PROPOSAL FOR ASSURANCE ON THE LIVES OF MINORS AND

NON-EARNING MAJOR LIVES
Name of life to be assured_______________________Proposal No___________________
Name of Proposer / Parent_____________________ Sum proposed_________________

1. If the life to be assured is attending School / College Please give:
(i) Name and address of the school / College Please give:
(ii) Class in which he / she is studying
(iii) If studying in college, his / her subjects of study : (e.g.Chemical / Mechanical /

Electrical Engineering, Mining etc and whether training in hazardous processes)
2. Full Particulars of Insurance Policies in force on the date of proposal, issued by any
Existing business unit of the Corporation on the lives of other members of the
family :
Members Name of Policy Sum Plan of Due Date Total

of the the Number Assured Assurance of last Premium
LA’s servicing premium paid /
family branch paid payable
during the
year
Indicate
Father,
Mother,
Brother,
Sister etc,
Total / Premium (per year)
3. Please state whether the premium under the resulting Policy would be financed from
HUF Funds or individual income. If paid through HUF Funds, please submit the
relevant addendum.
I hereby declare that the above statements are true in every particular and agree that they
shall form the basis of the contract of Assurance between me and the Life Insurance
Corporation of India.
172
I also agree to pay the premia under the policy, if and when issued, till the life assured starts
earning himself.
I am aware that the policy to be issued on the basis of the above proposal given by me will
automatically vest in the life to be assured:
i) On the deferred date in terms of special provisions incorporated in the policy.

ii) On his attaining the age of majority as provided for in the policy, and agree to it.
Place:
Date: Signature of Proposer / Father / Mother
N.B. : If the proposer signs in any other language or affixes his thumb impression, usual
vernacular declaration and / illiteracy declaration must be obtained over his signature /
thumb impression as the case may be.
173
SPECIMEN OF SUPPLEMENTARY DEED OF PARTNERSHIP
This supplementary deed of partnership is made between__________________________

________________________________________________________________________
________________________________________________________________________
on ______________________________________________________________________
whereas as all the partners in the firm working in the name of_______________________
____________________________felt it necessary to make provision of money in case of
premature death of any or more partners, it has been decided and agreed in between all the
partners to include the following clause in the original deed of partnership signed and
registered on_______________________clauseNo.__________ “It has
been agreed that in case of premature death of any of the partners to provide the money to
settle his account with the firm a life insurance policy be taken on the life of all insurable
partners with the Life Insurance Corporation of India for the sum mutually agreed between
all the partners. Premium for the said insurance / s be paid from the account of the firm. The
insurance is purchased with the express understanding to make the money available to the
firm to settle the Claim of deceased Partner / s”.
Signed at_______________________This ____________________day of__________20
Signature of partners
Witness:
______________________________ (1)
_______________________________(2)
_______________________________(3)
_______________________________(4)
_______________________________(5)
174
PERSONAL FINANCIAL QUESTIONNAIRE
1. Full Name of the Life to be insured :________________________________________
2. Please give details of occupation and state whether you are employed, self-employed, a
shareholding director or in a part___________________________________________
______________________________________________________________________
3. Please give details of your personal earning for the past 3 years
Particulars Year Year______ Year

_______ ______
Salary (including bonuses) or package
Income from House Property
Income from Business
Income/Commission from Profession
Share of Profit from Partnership Firms
Dividends
Interest from Tax Free Bonds
Income from Export Firms
Agricultural Income
Other Income(Please give details)
TOTAL
Q. Nos. 4 & 5 for Self-Employed Persons only
4. Business Details :
Name of Company/Partnership _____________________________________________
175
Nature of Business ______________________________________________________
When was the business established _______________________________________
Number of employees _________________________________________________
What percentage of the company’s share capital does the life to be insured own
______________________________%.
5. Please give details of the turnover, gross profit and net profit before tax for the last 3
years, and projected figures for the next financial year :
Year Turnover Gross Profit Net Profit

before Tax
Projected figures for next

Financial year
If a gross or net loss has been reported in these figures, please forward copies of the
last 2 years accounts and an explanation of why the loss occurred.
Where information is unavailable due to recent formation of the company, please

forward a copy of the current business plan including projections.
6. Please estimate the value of your assents and liabilities :
Assets Rupees Liabilities Rupees

House/Apartment Outstanding personal
loans
Land/Real Estate Mortgages on property
Bank Deposits(Fixed) Other liabilities(Please
Bank Deposits(Savings) Give details
Shares, Bonds(including
RBI and Other Tax Free
Bonds)
Mutual Funds
Post Office Savings (NSC,

Indira / Kisan Vikas Patra,
etc.)
Vehicles
Other(Please give details)
Declaration :
176
I do hereby declare that the above statements are true and complete and agree that this
Personal Financial Questionnaire together with proposal dated _________ shall form the
basis of the contract between myself and the Corporation.
Signature of life to be insured
Signature of the Official filling in Special MHR.
177
F 3251(Spl)
ANNEXURE A
LIFE INSURANCE COPORATION OF INDIA

-----------------------DIVISION
ADM (Sales) Marketing Manager’s Confidential Report.
Proposal No…………………………
Branch Office ………………………
INSTRUCTIONS:
1. This Report is to be completed where the Sum Proposed is in excess of Rs. 15 Lacs.
2. Before completion of the report the reporting official should satisfy himself regarding
the identity of the proposer. He should meet him, preferably at his residence before
completing the report. The reporting official should make independent enquiries about the
life to be assured's health and habits, occupation, income, social background and financial
position etc.
2. This report must be completed immediately after the enquiries are made:
______________________________________________________________________
3.
_1. Full Name of the
proposer...........................................................................................Age...........years.
Full Name of the life to be

assured..........................……................................................Age..........years.
Occupation:Exacat nature of
duties/Business.......................................................................
Sum proposed..................................
Full
Address......................................................................................................................................
………………………………………………………………………………………………..
2. Total previous insurance in force Sum Assured

Rs………………………
3. Total insurance premium per year for previous policies Rs.
4. (a) By whom were you introduced to the Proposer/ Life prop.

(a)………………………………………………………….
(b) Are you satisfied about the identity of the Life proposed
(b)…………………………………………………………..
178
(c) Give marks of identification, in any
(c)…………………………….
(d) Does the life proposed look older than the declared age (d)
……………………………
(e) What is the educational qualification of the life to be (e)
to be assured ?
(f) What is your assessment about the general state of health (f)
of the life assured ?
(g) Has he any physical deformity of impairment? (g)
(h) Does your enquiry indicate his having suffered from any (h)
illness or injury or undergone any operation or
Hospitalisation or medical investigation in the past?
If so, Give details.
5. Are you satisfied that no previous policy has lapsed within last
Three years on the life of the proposer / life proposed, his family
Member.
(The reporting official is expted to examine the entire family
insurance portfolio)
6. (a) What is proposer’s yearly income from (i) Employment: Rs…………………….
All sources (before tax) (ii) Business or Rs……………………
(Give detailed, and accurate Profession
information about the nature of
source) (iii) Agriculture Rs……………….
(iv) Investments Rs………………
(v) Property Rs……………………
(vi) Any other source Rs…………..
(b) Give information about the income,

total insurance in force and total
premium amounts per year for the
family members of the proposer.
Yearly income from Total insurance in Premium per year

all sources (before force
tax)
(i) Father
(ii) Mother
(iii) Wife / Husband
(iv) H.U.F
Of self
Of father
(If it is noticed that any earlier policies belonging to any one including the proposer’s are
financed from any of the HUF Funds, then give detailed information on the premium
amounts so paid, which HUF finances the policies, or whose life the policies are so
financed and what are the premium amounts)
179
(d) Give information about the Income, total insurance in force and total premium
amounts per year for the children of the proposer
Age Yearly Income from all Total Insurance Premium per

sources (before tax) year
Sons Rs Rs Rs
i)
ii) Rs Rs Rs
iii)
Daughters
i) Rs Rs Rs
ii) Rs Rs Rs
Iii) Rs Rs Rs
(d) Give the figure of Income Tax paid, Total Assets (excluding life assurance) &
Total Liabilities of the proposer, life Proposed & Family Members.
Income Tax Assets Liabilities

i) Proposer
ii) Life Proposed
iii) Father
iv) Mother
v) Wife /
Husband
vi) Sons
1.
2.
3.
vii) Daughters
1.
2.
3.
(e) Is he or his business solvent?

(f) State full particulars of the documents
Verified (Remarks such as “as told by
The party, agent etc” will not be accepted.
7. (a) Is there anyting in the Life to be Assured’s (a)

occupation, financial or social position,
personal habits or any other circumstances
which might add to the risk?
(b) Do you consider acceptance of the proposal (b)

as in order and recommend it as such?
I hereby declare that the foregoing statements are true and correct and are made as a result
of my detailed enquiries and on verification of documentary evidence.
Place: Signature:-----------------------------
180
Date: Name (Block Letters)---------------------
-----------------------------------------------
Designation-------------------------------
Address-------------------------------------
181
Form No, 3251 (Spl)
ANNEXURE B
Name Date:
Address
To
The Branch Manager,
LIC of India,
_______________Branch Office.
Dear sir,
Re: Proposal for Rs. on the Life of

Sri………………………………..
With reference to the above proposal submitted by me I have to inform you as

follows with regard to my income, insurance particulars etc.
1. My PA No. for Income Tax is :
2. My yearly income from all sources

Before tax is as particularised below:
i) salary Rs.
ii) Dividends Rs.
iii) Directors Fees Rs.
iv) Interest on Loans Rs.
v) Share of retained profits Rs.
vi) Net Income from property Rs.
vii) Agricultural Income Rs.
viii) Any other income (specify) Rs.
3. The total insurance on my life in force is to the extent of Rs.
4. Total amount of insurance premium per year for the

Above insurance is Rs.
I give below information about the income, total insurance in force, total premium
amounts per year for my family members.
182
Yearly Income from Total Insurance in Premium per year
All sources (Before force
Tax)
i) Father
ii) Mother
iii) Wife
iv) Sons
v) Daughter
Thanking you,
Yours faithfully,
(Name of the Proposer )
183
ANNEXURE TO THE CIRCULAR NO.: Actl./2018/4 dated 2nd May,2005
DETAILS OF EXISTING ACCIDENT BENEFIT (AB) COVER BEFORE THE DATE

OF THIS PROPOSAL
PART-I
UNDER LIC POLICIES AMOUNT

A INDIVIDUAL ASSURANCES
(i) INDIVIDUAL ASSURANCES (INBUILT, EXCLUSIVE)

(PLAN NO.91,111,123,124,125,126,128,140,149,150)
(ii) OTHER INDIVIDUAL ASSURANCES
SUB TOTAL OF A
B GROUP ASSURANCES
TOTAL OF A+B ( SAY X)

PART-II
UNDER OTHER INSURER'S POLICIES
(i) INDIVIDUAL ASSURANCES
(ii) GROUP ASSURANCES
TOTAL ( SAY Y)
GRAND TOTAL (X+Y)
…………………. ………………………
Life Assured Agent/DO
184
NRI QUESTIONNAIRES
185
Annexure – 1
Procedure for Mail Order Business
Medical Business
Completion of proposal form:
i. The proposal form should be completed by the proposer leaving no question

unanswered.
ii. The signature of the proposer on the proposal form must be witnessed by one
of the following after verifying the proposer’s passport:
• Designated Official of the local Indian Embassy; or

• Other Indian Diplomatic Representative; or
• If Diplomatic Representative not available, then by a Notary Public or a
Justice of Peace; or
• Medical Examiner.
• In the case of students, by the Dean / Principal of his/her college or the
Medical Examiner
iii. he witness must affix his office seal below his signature
iv. While getting the Proposal form witnessed, the proposer should produce his
original Passport, together with a Photostat copy of the FIRST PAGE thereof
before the Witnessing Official and get the same attested by the Official under
his official seal or by the Medical Examiner after verifying the proposer’s
passport.
v. This attested copy of the first page of the Passport must be submitted along
with the Proposal papers.
Note: Any fees payable for witnessing the proposal and attesting the copy of the first page
of the Passport as stated above are to be borne by the proposer.
Medical examination:
186
The life to be assured should approach a qualified doctor for medical examination as per
details given below:
Sum Proposed Medical Report from
Rs. 2,00,000 to Rs. 5,00,000 Graduate Doctor with 5 years standing
Rs. 5,00,001 to Rs. 10,00,000 Graduate Doctor with 10 years standing
Rs. 10,00,001 to Rs. 24,99,999 Post graduate Doctor with 5 years standing
Rs. 25,00,000 and over Post graduate Doctor with 10 years standing
Special Medical Reports:
i. The examiner / pathologist should establish the identity of the proposer on the
basis of his passport and should mention this fact on the report.
ii. The proposer should sign on the report in the presence of the examiner /
pathologist.
iii. The proposer should collect the report duly completed and signed from the
examiner / pathologist in a closed envelope.
iv. The special reports in closed envelopes alongwith the proposal form should be
handed over to the doctor conducting medical examination for sending the same
to the branch office of the corporation.
Other Rules:
i. Female lives should be examined only by a lady doctor. If the lady doctor is not
available the medical examination can be conducted by a male doctor provided
the female proposer has no objection for having full examination including per
vaginal examination without the aid of a nurse or a midwife.
ii. The proposer should complete the proposal form and get his signature attested
as per the rules in this regard.
iii. He/she should complete the NRI Questionnaire.
iv. He/she should get the special questionnaire completed and signed by the
employer / dean / principal / personal physician as the case may be, if no agent
visits him for completing the formalities.
v. He/she should get the special reports completed, if any, in closed envelopes.
vi. He/she should hand over the entire set of proposal forms including NRI/
Special questionnaire and special reports if any, to the doctor together with his
passport.
187
vii. He/she should sign at the bottom of the proposal form in the presence of the
doctor and the doctor has also to sign in the space provided for at the bottom of
the proposal form.
viii. The doctor will then examine the proposer on behalf of the Corporation and
send his/her report along with the other proposal papers including special
reports, if any, directly to the Branch Office of the Life Insurance Corporation
of India by Air Mail. For this purpose, the proposer should hand over a
stamped envelope with the address of the Branch Office to the doctor, so that
there would not be any delay in dispatch of the papers by the doctor.
ix. The proposer should collect the Passport from the doctor after the proposal
papers are sent by him to the Branch Office.
Fees for medical / special reports:
Fees payable will be as under:
Report Proposed Fees for Mail

Order Business
Rs.
Full Medical Report 400/-
ECG 400/-
CTMT 3000/-
Haemogram 300/-
Lipidogram 600/-
BST 300/-
SBT-12 2500/-
SBT-18 4000/-
RUA 100/-
Elisa for HIV 800/-
X-ray of chest 350/-
Fees payable will be the lower of the above prescribed fees or the actual fees paid subject
to the overall limit of 4 per thousand sum under consideration. Reimbursement of fees for
medical / special reports is made only when the proposal results into a policy.
Reimbursement of medical / special report charges on completion of proposal will be as

detailed in Circular ref. Actl./1912/4 dated 10th November 2003.
*****
188
Annexure – 2
AGENT’S CONFIDENTIAL REPORT / MORAL HAZARD REPORT

FOR MAIL ORDER BUSINESS
Agency Code Dev. Officer’s Code

Agent’s Name & Address Club Membership
Licence No. Date of Expiry
Name of proposer Age SP
When did you meet the proposer?
Are you related to him/her? If so, give details.
What is the educational qualification of the life proposed?
Give details of his source of income: Employment /

business, etc.
Details of proofs of income verified
Are you personally satisfied with the financial standing of

the proposer and justify the current proposal?
What is the general state of health of the proposer?
Does he have any physical deformity? – (impaired sight or

hearing, physical impairment or mental retardation)
Do you have any knowledge of his/her having suffered from

any illness or injury or undergone any operation or medical
investigation?
Status of his previous policies – inforce / lapsed?
Status of previous proposals - dropped / postponed /

declined / accepted with extra?
189
For Non-medical Cases only
Marks of identification
Height Weight Girth of Chest (cms) (over nipple)

(cms) (kgs) abdomen (cms)
Full expiration Full inspiration
(over navel)
hereby declare that the foregoing statements are true and correct to the best of my
knowledge and belief.
I also declare that I met the proposer when he visited India and explained to him the terms
and conditions of the plan. However, all the other formalities were completed during my
visit to the present country of the proposer’s residence.
At _______________on the ________________day of ____________ 200
Signature of the Agent
190
Annexure – 3
Divisional Office_______________ Branch Code____________
SPECIAL QUESTIONNAIRE TO BE COMPLETED IN RESPECT OF NRIs
Proposal No.______________
A. To be filled in by the Dean/principal in respect of students and Employer in

respect of employed persons
Name of the proposer

When did he join your college/university/firm?
Date of Birth and age
Educational qualification
General appearance
Any identification mark/s?
Does he have any physical deformity? –
(impaired sight or hearing, physical impairment
or mental retardation)
His professional status (type of duties performed)
Has he remained absent from college / duties on

medical ground? If so, period of absence and
reasons thereof
What are his habits / hobbies?
Does he consume tobacco, snuff or other narcotic
substances in any form, alcoholic drinks?
His per month salary / stipend / teaching
allowance
Results of any routine medical check-up
B. To be filled in by the Personal Physician in respect of self-employed persons
Name of the proposer
191
Since how long do you know the proposer?
Age of the proposer
General appearance
Any identification mark/s?
Does he have any physical deformity? –
(impaired sight or hearing, physical impairment
or mental retardation)
Has he taken any treatment from you? Yes/ No
If Yes, full details and the period of treatment
What are his habits / hobbies?
Does he consume tobacco, snuff or other narcotic
substances in any form, alcoholic drinks?
Any information about his financial status?
192
Annexure - 4

Divisional Office_______________
Branch Code____________
QUESTIONNAIRE TO BE COMPLETED BY NON-RESIDENT INDIAN
Proposal No.______________
Policy No.________________
Sr. No. Particulars
1. Yours Nationality
2. a. Your country of permanent residence

b. Date from which you became a permanent
resident of country mentioned in (a) above
3. a Date of leaving India for the first time

b. Details of exchange facility availed of
c. Full particulars of Reserve Bank Permit
Number
d. Visa status, if any
e. Name of Office of the Reserve Bank which
granted the above facilities
4. Duration of your stay abroad
5. a. Purpose of your stay abroad

b. Are you gainfully employed abroad?
c. Your monthly income from employment in
the foreign country (including Scholarship,
Assistantship etc for students or trainees).
Please enclose true copies of the
appointment letter received from your
employer or educational institutes.
6. a. Passport Number
b. Date of issue
193
c. Place of issue
d. Date of birth
7. Whether you hold any Bank account in

India and if so, whether it is a Resident
Account or Non-resident Account. Furnish
full details thereof
8. The source from which the premiums will

be paid
9. Please indicate by which of the following

manner you propose to remit the premiums
to LIC of India
a. By direct remittance from the country of
your residence to India through Banking
channels (preferably by Rupee Draft in
favour of LIC) Or by remittance through
postal channels like foreign orders.
b. By cheques drawn on your Non-Resident
(External) or Foreign Currency (Non-
Resident) Account with Bank in India
c. By cheques drawn on your Resident / Non-
resident Account with bank in India
d. By cheques drawn on account maintained
by resident parent or spouse of the
policyholder in their name or joint name
with other close relatives
e. By any other manner (please specify)
10. Your full address in the country of your

residence abroad
11. State full name and address of an Indian

National permanently residing in India to
whom the policy may be dispatched
12. Date of your leaving India / Date you left

India (current visit)
13. If you are a student state the nature and full

details of your studies
I hereby declare that the foregoing statements and answers are true in every respect and
I am agreeable for treating this as a part of the original Proposal Form. I am also aware
that claims of any nature arising under the policy will be settled in Indian currency in
India only. I have taken note of the restrictions applicable as given in the enclosed
annexure.
Dated at___________this____________day of_____________200
194
Signature of the life to be assured
Witness
Name
Address
Designation
Signature
Annexure – 5
CONDITIONS ON WHICH PROPOSALS ARE ENTERTAINED BY THE

CORPORATION ON THE LIVES OF NON-RESIDENT INDIANS
(AS PER EXCHANGE CONTROL REGULATIONS –
LIFE INSURANCE MEMORANDUM (LIM))
i. The life to be assured must be an Indian National or a person of Indian origin

temporarily residing in the country of his / her present residence.
ii. The life to be assured must hold a valid Indian passport.
iii. Policies in Indian Rupee currency only will be allowed either during their
temporary visit to India or on Mail Order Basis.
iv. The premiums under the policies shall be paid by any of the following
manners:
a. By direct remittance from the country of his / her present

residence through banking channels.
b. By cheques drawn on his / her Non-Resident (External) Account
or Foreign Currency (Non-Resident) Account with a Bank in
India (or Joint Account provided the policyholder is one of the
accountholders).
c. By cheques drawn on bank accounts held in India in their own
names, either solely or jointly with the resident member of their
family, i.e., father, mother, husband, wife, children, brother or
sister, whether the accounts have been designated as Non-
Resident or not.
d. By cheques drawn on an account maintained by a resident parent
or spouse of the Non-Resident policyholder with a bank in India,
held solely or jointly with their close relatives. If the life assured
is a bonafide student, premiums can be accepted if paid in India,
by somebody else on his behalf.
e. By the absolute assignee in India wherever such policies have
been assigned to a resident in India.
f. By the employers in respect of policies issued to their employees
who have been deputed abroad by them.
195
g. Premiums can be paid in cash by a resident parent or spouse of
the Non-Resident policyholder subject to his / her submitting a
letter stating the relationship with the policyholder.
(Note: In respect of premium collection in cash or from sources

mentioned in c, d, e & f above, it should be noted that the policy
moneys cannot be paid abroad in foreign exchange but has to be
paid in India only)
v. Settlement of Claims
• • The basic rule – settlement of claims on rupee life insurance

policies in favour of claimants resident outside India will be permitted in
foreign currency only in proportion in which the amount of premiums
paid in foreign currency in relation to the total premiums payable.
• Non-resident beneficiaries
- Non resident beneficiaries of insurance claims / maturity / surrender

value settled in foreign currency may be permitted to credit the same to
NRE (Non-Resident External) / FCNR (Foreign Currency Non-
Resident) account, if they so desire.
- Claims / maturity proceeds /surrender value in respect of rupee

life insurance policies issued to non-resident Indians for which
premiums have been collected in non-repatriable rupees may be paid
only in rupees by credit to NRO (Non-Resident Ordinary) account of the
beneficiary. This would also apply in cases of death claims being settled
in favour of non-resident assignees / nominees.
• Resident beneficiaries of insurance claims / maturity / surrender values

settled in foreign currency may be permitted to credit the same to RFC
(Resident Foreign Currency) accounts - if they so desire.
vi. The restrictions in regard to export of policies have been withdrawn.
*****
196
Annexure - 6
LIST OF COUNTRIES WITH RESIDENCE RATING
The above guidelines have been further reviewed and it has now been decided to reclassify
the countries into eight Groups – Residence Group I to Residence Group VIII as shown
below:
Residence Group I
Residence Group I will include the following 26 countries:
Afghanistan Haiti Rwanda

Algeria Iraq Sierra Leone
Burundi Israel - Westbank, Gaza, Somalia
Central African Republics Jerusalem Sudan
Chad Ivory Coast Tajikistan
Chechen Republic Liberia Venezuela – remote areas
Democratic Republic of the Macedonia Western Sahara
Congo (Zaire) Niger Yemen
Ethiopia North Korea
Guinea Palestine
NRIs residing in the above 26 countries will be allowed insurance cover without charging
any residence extra:
i. Under Table Nos. 48, 152, 162, 171, 167 and 175
- with Single Premium Mode (for Table No. 167 with premium paying term 3
to 5 years)
- maximum policy term of 15 years
- Maximum Sum Assured of Rs. 10 lacs
ii. Without any limit under Table Nos. 148 (New Jeevan Dhara I) and 172 (Future
Plus) if without life cover
iii. Table No. 170 (Jeevan Akshay III) without any limit
Residence Group II
Residence Group II will include the following 37 countries:
Albania Guatemala South Africa
197
Angola Guinea – Bissau (except Cape Town,
Azerbaijan Indonesia – Other Johannesburg, Pretoria,
Belarus Iran Bloemfontein, Durban)
Bosnia / Herzegovina Kyrgyzstan Swaziland
Casamance Madagascar Togo
Colombia Mali Tanzania
Comoros Island Montserrat Uganda
Congo (Brazzaville) Nigeria Uzbekistan
Egypt – (other than Cairo) Panama Yugoslavia (Serbia,
El Salvador Papua New Guinea Montenegro, Kosovo)
Equatorial Guinea Russia – other Zambia
Eritrea Senegal Zimbabwe
Georgia Solomon Island
NRIs residing in the above 37 countries will be allowed insurance cover without charging
any residence extra:
to 5 years)
- Maximum sum Assured of Rs. 25 lacs
ii. Without any limit under Table Nos. 148 (New Jeevan Dhara I) and 172
(Future Plus) if without life cover
NRIs residing in countries mentioned in Residence Group I and II will not be

allowed insurance under other plans.
Residence Group III
Residence Group III will include the following 6 countries:
Ecuador Laos Myanmar

Jamaica Mongolia Tibet
NRIs residing in the above 6 countries will be allowed cover with a residence extra of Rs. 5
%0 for a maximum rated up sum assured of Rs. 25 lacs. The insurance will be offered under
plans other than pure term insurance (Table Nos. 43, 52, 58, 164 & 177). Term rider and CI
riders will also not be allowed.
Residence Group IV
Residence Group IV will include the following 17 countries:
198
Botswana Honduras Mozambique
Cambodia Kazakhstan Nicaragua
Cameroon Lesotho Paraguay - remote areas
Djibouti Libya Peru
Gabon Malawi Syria
Ghana Moldova
NRIs residing in the above 17 countries will be allowed cover with a residence extra of Rs.
4 %0 for a maximum rated up sum assured of Rs. 25 lacs. The insurance will be offered
under plans other than pure term insurance (Table Nos. 43, 52, 58, 164 & 177). Term rider
and CI riders will also not be allowed.
Residence Group V
Residence Group V will include the following 7 countries:
Armenia Israel – Tel Aviv Philippines Ukraine

Gambia Lebanon Turkmenistan
Residence Group VI
Residence Group VI will include the following 8 countries:
Bolivia Indonesia-Major Cities Vietnam

Bulgaria Kenya Venezuela –Caracas
China (except Beijing & Shanghai) Namibia
Residence Group VII
Residence Group VII will include the following 18 countries:
Argentina Croatia Paraguay – Ascunsion

Benin Cuba Russia – Major Cities
Brazil Dominican Republic Suriname
Brunei Guyana Tonga – Nuku’alofa
Burkina Faso Mauritania Tunisia
Costa Rica Micronesia Turkey
NRIs residing in the above 18 countries will be allowed cover with a residence extra of Rs.
1 %0 for a maximum rated up sum assured of Rs. 50 lacs. The insurance will be offered
199
under plans other than pure term insurance (Table Nos. 43, 52, 58, 164 & 177). Term rider
and CI riders will also not be allowed.
In addition to the above, NRIs residing in Residence Groups III to VII can be allowed cover
without charging any residence extra:
to 5 years)
- Maximum sum Assured of Rs. 50 lacs
ii. Without any limit under Table Nos. 148 (New Jeevan Dhara I) and 172
(Future Plus) if without life cover
Residence Group VIII
Residence Group VIII will include the following 56 countries
Australia Egypt – Cairo only Malaysia- Kuala Seychelles

Austria Fiji Lumpur Singapore
Bahamas Finland Maldives South Africa (Cape Town,
Bahrain France Mauritius Johannesburg, Pretoria,
Bangladesh Germany Mexico Bloemfontein, Durban)
Barbados Gibraltar Nepal South Korea
Belgium Greece Netherlands Spain
Belize Hong Kong New Zealand Sri Lanka
Bhutan Hungary Norway Sweden
Canada Ireland Oman Switzerland
Chile Italy Poland Taiwan
China – Beijing Japan Portugal Thailand - only Bangkok
& Shanghai Jordan Qatar UAE
Cyprus Kuwait Romania UK
Denmark Luxemburg Saudi Arabia USA
Proposals from NRIs residing in the above 56 countries can be accepted without charging
any residence extra and in accordance with the existing guidelines applicable to NRIs.
However, critical illness rider will not be allowed.
General Points to be considered while allowing insurance cover to NRIs residing in all the
eight residence groups:
i. The residence ratings shown above are to be applied to Class I occupations, such
as – managerial, skilled, high paying desk job type employment with proof, etc.
200
ii. Residence ratings for Class II occupations such as semi-skilled, unskilled labour,
highly paid job involving significant manual labour or high occupational risk,
excessive traveling or low paying jobs, will be 1.5 times the residence extra for
respective residence group.
iii. Proposals from proponents attracting health extra of Class III and above and
with class II occupations are to be regretted.
iv. Proposals for high sum assured (above Rs. 25 lacs) will be considered only from
persons employed in Class I occupation.
v. Income proof like salary certificate or employment contract will be insisted

upon.
vi. KMI / partnership insurance will not be allowed.
vii. Cover on the lives of housewives, children residing in countries mentioned

under residence groups I to VII will not be allowed.
Proposals from NRIs residing in the remaining countries
Proposals from NRIs residing in countries other that those mentioned above under all
groups (I to VIII) should be sent to CUS for individual consideration.
There is no change in the other guidelines relating to granting insurance cover to NRIs.
The above instructions come into force with immediate effect.
Chief (Actl)
201
LETTERS TO PROPOSERS / POLICY HOLDERS
202
Form No 3107

Branch Office……………
Dear Sir/Madam,
Sum Proposed Branch

Dev. Officer's Name
Agent's Name
Code Numbers
Proposal Plan and Term Name of the Life to Age Proposal / Policy Deposit
No. & Date of Assurance be assumed
Rs. P
Decision of
Corporation
We thank you for your proposal for assurance but regret to inform you that it is not
possible to accept this proposal at present. The consideration of your proposal is postponed
for the period mentioned above.
Your proposal can be reconsidered only after the expiry of the postponement period
mentioned above.
In view of the postponement kindly let us know if we may refund the deposit of Rs.
paid under the proposal subject to the cost of medical examination/special reports fees. Till
we hear from you we shall be retaining the proposal deposit with us for the time being
without any commitment for acceptance of your risk cover or payment of interest thereon.
Yours faithfully,
203
p. Sr / Branch Manager
204
Form No.3108

Branch Office……………..
Dear Sir/Madam,
Sum Proposed Branch

Dev. Officer's Name
Agent's Name
Code Numbers
Instalment
Proposal Plan and Term Name of the Life to Deposit,
Age Premium &
No. & Date of Assurance be assumed if any
Mode
Rs. P Rs. P
Decision of
the
Corporation
With reference to your proposal for assurance, we regret to inform you that after
consideration of all the circumstances of the case, we are unable to cover the proposed risk
and have accordingly declined your above proposal. Our cheque for the refund of deposit (if
any) paid by you will follow shortly.subject to the deduction of cost of medical
examination/ special reports fees.
Yours faithfully,
p. Sr. /Branch Manager
205
Form No. 3109
Ref:..........................................

BRANCH OFFICE………………
Date ..................................
Dear Sir/Madam,
Re :- Proposal No. Own Life
We thank you for your above proposal.

To enable us to proceed with the consideration of the same, please arrange to submit the
following requirements mentioned against item No..............................................
1. Please return the enclosed ............................................Form duly completed.
2. Please confirm Table, Term, Mode of payment and the sum to be assured as they are
altered in the Proposal Form without your initials thereon.
3. Satisfactory evidence of your age acceptable to the Corporation, e.g. Birth or

Municipal or School or College or Baptismal Certificate, etc., as your age is not
admitted in your previous Policy.
4. Please let us know the line of your studies.
5. Your Declaration to the Proposal Form in your own handwriting to the effect that
the answers have been written at your dictation and you warrant their correctness.
6. A Short Medical Report on the enclosed Form/Full Medical Report, from any of our
authorised Doctors who has not examined you during the preceding two years for
life insurance/the Doctor named below in Item No.16.
7. Please arrange to submit ....................................Report by the Doctor named below

in the Item No.16. A fee of Rs...............................is to be paid by you in the first
instance, and the same will be reimbursed to you to the extent of Rs.4.00 per
thousand sum assured including the fee for the routine medical report on production
of Doctor's receipt, and when the proposal results into a Policy.
8. Please call on the Doctor named below in Item no.16 for further examination. Please
note that no fees are payable to the Doctor.
9. Please make it convenient to call on us at the address given above on any working
day except Saturday, between 11 - a.m. and 1-00 p.m. or 2-30 p.m. and 5-00 p.m. or
on any Saturday between 11-00 a.m. and 1-00 p.m.
206
10. On comparison with previous papers, we observe a fall of ......................... kgs. in
your weight since the date of your last proposal. Please let us know the reasons for
the same and state since when your weight is stationary increasing.
11. Please let us have your reply to Question No...........................of the Proposal
Form/Personal Statement which reads as follows :-
12. Your previous Policy No............................has lapsed/was paid up during the

preceding three years. As per our rules, the revival of said Policy is essential before
we can consider the present proposal. Please arrange for the same and inform us
when it is revived.
13. Please arrange to submit your Income-Tax Assessment Orders for the last three
years for our perusal and return.
14. If the proposal does not result into Policy, an initial expense towards medical fees
will be recovered.
15. Please let us have the details of Life Insurance Policies on your life as also of your
family members.
16.
In case of any difficulty, you may please contact our Agent/Development Officer
who has been instructed to render you all the necessary help in the matter.
Assuring you of our best services.
Encl.
Yours faithfully,
p.Sr./ Branch Manager
207
Form No. 3110

BRANCH OFFICE……………
Ref : .......................................... Date ..................................
Dear Sir/Madam,
Re :- Proposal No. ..................................................

On the life of ...................................................
We are in receipt of your above proposal for assurance and while thanking you for
the same. We have to request you to furnish the following requirement(s) numbered
........................... to enable us to proceed with the consideration of the proposal.
1. A balance amount of Rs...........................P............................towards the first

premium as your proposal can be considered under Plan and term
.......................... instead of the plan and term proposed by you/with an extra
Rs.......................P........ per thousand sum assured per annum on medical
grounds/on account of your occupation.
2. A sum of Rs...............................P.........................being the difference

between the instalment premium and the amount paid by you as deposit
under your proposal.
3. Your consent on the enclosed form to (a) the terms indicated in 1 above, (b)
the special condition as per .....................................Clause attached herewith,
(c) exclusion of Accident Benefit/Permanent Disability Benefit.
4. Declaration of continued good health of the life to be assured on the

enclosed form.
5. Amount of Rs.......................P............................being the interest at 8% on

the premium for dating back the Policy to ..............................
6. Satisfactory evidence of age of Life to be Assured, acceptable to the

Corporation, e.g. Birth or Municipal or School or College or Baptismal
Certificate etc. as the age is not admitted in the previous Policy.
7. Please return the enclosed Form No.........................duly completed.
208
8. If the requirements mentioned above are not received within 30 days from
the date of this letter, evidence of continued good health of the life to be
assured may have to be produced at your expense.
Assuring you of our best attention at all times.
Yours faithfully,
Sr/ Branch Manager
Encl:
P.S Payment referred to in 1, 2 & 5 above should be remitted to our branch

office at the following address :-
209
Form No 3162

Date. ……………….
From : ……………………………………. To : …………………………….
BRANCH DEVELOPMENT
OFFICER/AGENT
Re : Proposal No………………….
The above party has completed the Proposal Form in ……….. but has signed the
same in …………….. In consequence, a declaration in the Proposer’s own language to the
effect that the same, was required to be made thereon. As this has not been done, please
obtain from him such a declaration on a separate paper and forward it to us at an early date
to enable us to proceed with the consideration of the proposal. The text of declaration
should be translation of the wording of Form No 3193.
Form No. 3164

Ref:
Dear Sir,
Re: Proposal No.-----------------------------

With reference to your Medical Report dated the--------on the above life, you have
omitted to answer certain questions reproduced below.
Please enter against question your reply thereto, after referring to your notes and
return the form immediately to enable us to proceed with the consideration of the proposal.
We have to request you to revise your reports thoroughly in future and make sure
that they are complete in every respect before forwarding them to us.
Yours faithfully,
p. Sr./Branch Manager
I
Questions I Answers
I
I
I
Date: Signature of Medical Examiner
210
Form No 3168

Dear Sir,
Re: Proposal No.-----------------------------------------------------------------on your own life
We thank you for your above proposal.
We find from the Form of Addendum to the Proposal completed by you that you
have appointed yourself/ Shri /Smt---------------------------------------------------------
who is/ the beneficiary/ one of the beneficiaries, as a Special Trustee/ one of the Special
Trustees, to receive the Policy Moneys and to hold the same in trust for the said beneficiary
/ beneficiaries under the provision of the M.W.P.Act, 1874.
Although, there would appear nothing in law to prevent such an appointment being
made, the Life Assured himself / the beneficiaries himself / herself, as a general rule is not a
fit person for the Office of a Special Trustee in view of the probability of a conflict between
his / her interest and duty.
In view of the above, we would strongly suggest that you appoint some other person
of your choice to act as a Special Trustee instead of the proposed arrangement.
If you approve of our suggestion, please send us the enclosed fresh form of
Addendum to Proposal duly completed in cancellation of the earlier one already submitted.
If however, you are not agreeable to our suggestion, please let us know to that effect
to enable us to proceed with the proposal.
An early action will be highly appreciated,
Yours faithfully,
Encl: 1 Form of Addendum to Proposal
211
Form No 3170
REGISTERED
Dear Sir,
Re: Proposal No……………………………..
We are in receipt of ……………………..in proof of your age and have to inform

you that the age is found to be in order. A note to this effect will be made on the Policy if
and when issued. Your date of birth as recorded by us is……………………..
The proof is returned herewith, receipt of which please acknowledge.
Yours faithfully,

Encl: 1
212
Form No 3171
Dear Sir,
Re: Proposal No……………………………..
With reference to your above proposal, we regret that the declaration of age which you
intend to submit is not acceptable to us as conclusive evidence of age. We find that you
have not mentioned in the proposal the nature of age proof which you intend to submit. We
require any of the following documentary proofs to enable us to admit age in our records:-
1. Certified Extract from Municipal or other records made at the time of Birth.
2. Certificate of Baptism or Certified Extract from Family Bible if it contains
Age ar Date of Birth.
3. Certified Extract from School or College Records of Age or Date of Birth as
stated therein.
4. Certified Extract from your service record if you are a Government Servant
or are employed in a Quasi- Government Institution.
5.
We have, therefore, to request you to let us have any one of the above mentioned
document at your earliest convenience.
Yours faithfully,
213
Form No 3176
Station……………………………………
Date……………………………………….
Dear Sirs,
Re: Standing Instructions for, payment of Life Insurance Premium
Until further notice please note as standing instructions to pay to the Life Insurance
Corporation of India........................................ the monthly premium on the following
Proposal every month regularly and debit my account. Your charges may also be
debited to my account.
When the proposal results into a policy, the Corporation will inform you of the same
along with the due date of premium and thereafter the Policy number should be quoted
while sending the remittance. The remittance should be made on or before the due date.
Number of current Deposit Account :
Proposal / Policy No. :
Amount of Premium :
Date of Payment : and every month thereafter.
In undertaking to make these remittances it is expressly understood that the Bank is

relieved from all claims for loss which may accrue through error, omission or delay in
making such remittances.
Name in full : Yours faithfully,
Address: --------------
Signature
214
Form No 3179

Branch Office,
Dear Sir,
Re: My proposal dated…………………….
With reference to my above proposal , I hereby agree to the extra premium being charged at the rate of
Rs……………..per thousand sum assured per annum on account of *
Health Grounds,
And / or Occupation/ residence viz…………………………………………………………………………
………………………………………………………………………………………………………………**
and or physical condition, viz……………………………………………………………………………….**
I also agree to permanent disability benefit being excluded from the privileges under the policy resulting from
the above proposal***
Date………………………………………..
* Delete what ever is inapplicable

** Here insert the occupation / residence as given in Appendix “A” or the physical impairment and ailment as
mentioned in Annexure “C” of the Agent’s manual.
*** Delete if there is no physical defect or deformity.
215
Form No 3181
Ref:
Dear Sir, Date…………….
Re: Proposal No ……………..

Policy No…………………….
Enclosed please find our cheque for Rs…………….being the amount of refund of deposit less medical fees
paid by you in respect of the above proposal /policy.
Yours faithfully,
p.Sr / Branch Manager
Encl: Cheque
216
Form No 3185 (Rev)
Ref:
………………………. Date…………….
……………………….
……………………….
Dear Sir,
Re: Proposal No………………….
Your cheque for Rs ……………..in payment of first premium in respect of the above proposal was dishonoured.
Our First Premium Receipt and policy already issued to you, therefore, stand cancelled. Please return these two
documents for cancellation.
On receipt of a fresh remittance of Rs………….including the bank charges of Rs………and……., we

shall consider reinstatement of the policy contract.
Yours faithfully,
N.B.: Call for DGH, SMR or FMR if any required as per rules.
Form No 3193
Addendum to Proposal No. own life
I,…………have completed the Proposal Form relating to the above proposal in………
But have signed it in………I hereby declare that all the questions in the Proposal Form were duly
explained to me and I have given my replies after fully and properly understanding the same.
217
DECLARATION TO BE MADE BY THE PROPOSER UNDER JEEVAN VISHWAS PLAN

Proposal No:-________________________ Proposal dated:-________________
I hereby declare that ____________________________________aged____________years is physically/

mentally handicapped and is dependant on me.
Place:
_______________________________
Date: (Signature of the proposer)
Name and address of the Proposer :_____________________________________________________

__________________________________________________________________________________
_______________________________________________________________________________
218
Form No. 3232
Registered
Dear Sir,
Re: Policy No………………………..Own Life
We have pleasure in enclosing herewith your above mentioned Policy.
We observe from the papers that you intend to finance the payment of premiums under the
Policy out of your contributions to your Provident Fund Account. The Policy will, therefore have
to be assigned to the authorities of the Provident Fund concerned.
In order to ensure that the assignment is effected as early as possible, we give below the pro-
cedure to be followed for that purpose :--- .,
(i) The rules of some Provident Funds require the Policyholder to assign the Policy in the
first instance in favor of himself and the person who has been appointed as the nominee
of the Provident Fund Account, in a joint tenancy Form, and then to execute another
assignment jointly with the co-assignee in favor of the Provident Fund Authorities. In
such cases, two assignments are required to be executed. The rules of some other
Provident Funds, on the other hand, require the policyholder to assign the Policy
directly to the Provident Fund Authorities, in which case only 'one assignment is
necessary. The wording/s of the assignment/s and the manner of execution thereof are
prescribed by the respective Provident Fund Authorities to which the Policy is to be
assigned. You may immediately on receipt of this Policy, apply to the authorities of
your Provident Fund Account and obtain from them the wording/s. of the assignment/s
to be executed on your Policy for the purpose.
(ii) You may then copy out the wording/s of the assignment/s on the back of the policy and
assignment/s should then be dated, signed by the respective assignors, and witnessed in
accordance with the manner prescribed by the Provident Fund Authorities. Please make
a copy/ies of the assignment/s.
(iii) A notice of each assignment is required to be given to the Corporation. If you are
required to execute two assignments as explained in (i), it will be necessary for you to
send us two notices, one as per the enclosed Form No. 3868A to be signed by you and
another as per the enclosed Form No. 3868B to be signed by you jointly with the co-
assignee. If, on the other hand, you are required to execute only one assignment directly
in favor of the Provident Fund Authorities, you may send us a notice as per enclosed
Form No. 3233.
(iv) After the assignment/s is/are executed, please forward the Policy to us along with
copy/ies thereof and the notice/s of assignment/s, to enable us to register the
assignment/s in our books.
The Policy will be returned to you or forwarded to the Provident Fund Authorities, as may
be desired by you, after registration of the Assignment/s, in our books. While sending us the Policy
please advice us as to whether the Policy is to be returned to you or forwarded to the Provident
Fund Authorities.
Encl ; (1) Policy(2) Forms of Notices Yours faithfully,
Nos.3868A, 3868B, & 3233
p. Senior / Branch Manager
219
REGISTERED Form No. 3234
Re : Policy No............
Dear Sir,
We have the pleasure to send herewith your abovementioned policy.

(i) We observe that the relationship/age of the nominee under Section 39 of the Insurance Act,
1938, is not mentioned in the proposal form. Kindly, therefore, let us know the same for our
record.
After the appointment has been executed as above, please forward the policy to us along
with the form of appointment similarly executed to enable us to register the
appointment in our books.
(ii) Please note that we have not incorporated in the policy document the name of the person
appointed to receive the policy moneys in case of claim arising during the minority of the
nominee as the appointment has not been properly executed in the proposal form signed by
you. To enable you to make a proper appointment a copy of our usual from of appointment
of an appointee is enclosed for your use. Please copy out the wording of the form at the
back of the above policy after making such alterations in the wordings of the form as may
be deemed necessary. Thereafter, please affix your signature along with that of the
appointee in the presence of an English knowing witness and mention the place and the
date of your doing so. The witness should be asked to affix his signature at the appropriate
place and to mention in full his name, designation and address below his signature. We
may point out that without the signature of the appointee indicating his acceptance the
appointment will be inoperative.
Encl : 1 Policy
1 Form p.Sr/Branch Manager
220
Form No 3239
………………….. ………………..Office
………………….. Date……………
Dear Sir,
Policy No………………………………
We have the pleasure to forward herewith the above policy document which please find in
order. We would specially draw your attention to the special provision mentioned in the schedule
of the policy in terms of which certain options are available to you. The details of the options and
the method of availing the benefits of the options are stated therein.
It is important that the conditions mentioned therein are noted carefully as it will be helpful
to you, in case you decide to exercise the option at a future date. It is also essential to note that the
option has to be exercised in the right manner and during the stipulated time limit. In case the
policy is not received by the assured / you till now, please write to us immediately to enable us to
take up the matter with the postal authorities on our side in time, as they do not entertain any
complaints after six months from the
Yours faithfully,
p. Sr/ Branch Manager.
221
Form No 3242

Dear Sir,
Re: Policy No……………………………
With reference to your letter of the ……………………………we advise having despatched the
above policy to the assured/you by Registered Book Post on………………to the address given in
the proposal form.
In case the policy is not received by the assured / you till now, please write to us immediately to
enable us to take up the matter with the postal authorities on our side in time, as they do not
entertain any complaints after six months from the date of sending an article.
If we fail to hear from the assured/you within a reasonable time, we shall presume that since
writing to us, the Policy has been received by him .you.
Yours faithfully,
p.Sr./Branch Manager
222
Form No 3242 A
Ref : NB Branch Office :

________________________
________________________
________________________
_________________ Date :
_________________
_________________
_________________
Dear Policyholder,
Re: Your Policy No.___________________________
With reference to your letter authorizing your agent to collect the policy bond of above policy
from us, we advise having sent the same through your agent. We hope you would have received
the policy bond by now.
In case the policy is not received by you till now please write to us immediately to enable us to
take up the matter with the concerned agent.
If we don’t hear from you within 15 days from the date you received the policy we shall presume
that you have received the policy and the same has been found by you in order.
Thanking you,
Yours faithfully,
223
Annexure ‘B’
Ref : NB Branch Office :

________________________
________________________
________________________
_________________ Date :
_________________
_________________
_________________
Dear Policyholder,
Re : Your Policy No. _______________
We have pleasure to forward herewith the above policy document which please find in
order.
We would also like to draw your kind attention to the information (including special
provisions, if any) mentioned in the Schedule of the policy and the Conditions & Privileges given
including the options stated therein. The details of the options and the method of availing the
benefits under those options are also mentioned.
It is important that the conditions mentioned in the policy are noted carefully as it will be
helpful to you, in case you decide to exercise the option at a future date. It is also essential to note
that the option has to be exercised in the right manner and during the stipulated time limit.
As per IRDA (Protection of Policyholders’ interests) Regulations, 2002 we would request
you to go through the terms and conditions of the policy and in case you disagree to any of the
terms and conditions, you may return the policy within a period of 15 days stating the reasons of
your objections. On receipt of the policy we shall cancel the same and the amount of premium
deposited by you shall be refunded to you after deducting the risk premium and charges for
medical examination and stamp duty.
We would also like to draw your attention to the following two aspects :
1) Change of Address : Kindly ensure that you inform any change of address to the servicing
branch in case you change your residence.
224
2) Nomination : To facilitate speedy settlement of claims kindly ensure that you have
nominated a beneficiary to receive the benefit under the policy. You may change the
nominee under the policy, in case you wish to do so.
These measures will enable us to serve you better.
Thanking you,
Yours faithfully,
p. Sr. / Branch Manager
225
Annexure “A”
Ref :NB Divisional Office, with Address

……………….. ………………………………….
……………….. ………………………………….
……………….. ………………………………….
Dear Sir,
Re: Your Proposal No……………………..dated……………….
We acknowledge your above proposal along with a remittance of Rs…………..through

your agent Mr / Mrs………………………….., under Agency Code No…………..
Your proposal has been sent by us to our higher office for underwriting decision.
We shall revert to you soon in this matter.
Thanking you,
Yours faithfully,
p. Sr. / Divisional Manager

Note: Please note that this is just an acknowledgement of your proposal and does not, in any way
constitute acceptance or commencement of risk.
226
REGISTERED BOOK POST
Form No 3243
Dear Sir,
Re: Policy No……………………………………
As requested by…………………………………….we have the pleasure to enclose herewith the

policy issued in your favour, which was returned to us undelivered by the Postal Authorities.
Kindly acknowledge receipt of the policy at an early date.
Yours faithfully,
227
REGISTERED BOOK POST Form No 3244
Dear Sir,
Re: Policy No……………………………………
We posted on………..by Registered Book Post under your receipt No………our Life Policy
bearing the above number to the Policy holder at the following address:-
We are now informed that the addressee has not received the policy. We have, therefore, to
request you to make an inquiry as to why the policy was not delivered to the party in due course.
If the policy has been subsequently delivered to the addressee please advise us accordingly. If not,
it may please be returned to us undelivered in the usual course.
Yours faithfully,
228
Form No 3245
From, To,
………………………… ………………………………
Re: Policy No………………………………….
We have to inform you that the above policy, which was posted to the policy holder direct to his address
given in the proposal form, has been returned to us undelivered by the postal authorities with
remarks…………………………………..Please let us have the correct present address of the policy holder to
enable us to forward the policy document to him as early as possible.
p.Sr / Branch Manager.
229
Form No 3892
Dear Sir,
Policy No.______________________________________________ own life
We are forwarding herewith the above policy along with a true copy of the same, duly issued under
the provisions of Section 6 of the Married Women’s Property Act, 1874, for the benefit of Your-------
------------------------------------------------------------
( Relationship and name of the beneficiary)
Since the Special Trustee appointed by you____________________________
(Name of the Bank / Trustee Co)
require you to record their appointment as Special Trustee on the policy under your hand we have
typed on the back of the policy and also on the certified copies thereof the wording of the
endorsement prescribed in this behalf by this Bank / Trustee Co. Please affix your signature to the
endorsement and insert the place and date of your so doing in the presence of a witness who should
attest the same. After this is done, please forward the policy and its certified copy to the Bank /
Trustee Co. for endorsing its acceptance of the trust under the policy. The Bank / Trustee Co. will
retain the original Policy in its safe custody and return the certified copy of the policy to you for your
records.
While forwarding the policy to the _________________________________________
(Name of the Bank / Trustee Co.)
with a covering letter as per draft enclosed herewith, you may also remit to them their retainer fee in
advance if the Special Trustee require you to do so.
Please take action as advised herein at the very earliest. The effect of your not executing the
endorsement of appointment of Special Trustees and the Special Trustee not accepting the trusteeship
thereat would be that there would not be any appointment of Special Trustee.
Encl : 1. Policy Document Yours faithfully,

4. Copy Policy
5. Draft letter p. Sr / Branch Manager
Copy to (Institutional Trustee)
__________________________
__________________________
__________________________
230
Form No 3893

Full Name and Address of the assured
Full name and address of the Bank / Trustee Co.
Dear Sir,
Re: Policy No.___________________________________on my own life
I, the undersigned, have obtained from the Life Insurance Corporation of India, a policy of
Rs…………………issued under the Married Women’s Property Act, 1874, and the said policy is for
the benefit of ___________________________aged_______
(Relationship & Name)
I have appointed you as a Special Trustee under the said policy and as such I hereby authorize you to
charge your commission as per your rates currently in force.
* I understand that I am required to pay to you your retainer fee in advance. Accordingly, I am
arranging payment of the sum of Rs………………towards it. I understand that the said sum will be
taken in to account when you recover your commission. I also understand that in case of revocation
of your appointment, you will not refund the said sum of Rs……………..
* I understand that you would recover your commission charges from out of the policy moneys.
I also enclose herewith the original policy document together with a certified copy of the same. I
have executed thereon the endorsement appointing you as the Special Trustee. Kindly endorse your
acceptance of the trusteeship thereon and arrange to return the copy policy to me for my records and
the original policy to LIC of India for registration of your appointment by me as Special Trustee and
your acceptance of the office of Special Trustee.
Yours faithfully,
Signature of the Life Assured
Copy to LIC of India
Address of DO/BO
231
Form No 3895
Dear Sir,
Policy No___________________________________________own life
We are forwarding herewith the above policy duly issued under the provisions of the Married
Women’s Property Act, 1874 for the benefit of
your_______________________________________________________
________________________________________________________________
(Relationship & name of the Beneficiary)
A certified copy of the policy document is also enclosed for your record.
Please now deliver the original policy document to the Special Trustee for safe custody.
Yours faithfully,
Copy to:______________________________________________________
(Full Name & Address of the Bank / Trustee Co.)
for information and necessary action.
232
REPORTS
233
Form No. 3311 (a)
LIFE INSURANCE CORPORATIONOF INDIA

REPORT OF GLUCOSE TOLERANCE TEST OF URINE
Proposal No ……………………………
Agent’s Name and Code No. ……………………………………………………………………
Name of the Life to be Assured …………………………………. Age…………
(IN BLOCK LETTERS)
Introduced by ………………………………………… His Signature ………………………….
Instructions for the Pathologist
1. Please ensure that Life to be Assured presents himself before you in the morning and that his
bladder is completely emptied in your presence. Test the urine then passed by the usual Fehling’s
and Benedict’s Test.
2. Then administer 75 gms. of pure glucose dissolved in four ounces of water. Examine a specimen
of the urine passed two hours later.
3. Each column should be filled completely in every case.
4. Please give both the quantity as well as the Specific Gravity of Urine while examining the urine.
SAMPLE Time O’ Clock Quantity Specific Urine

Gravity Glucose %
Before administration
of Glucose
Two hours after

administration of 75
gms. of Glucose
QUERIES TO BE ANSWERED CORRECTLY BY THE LIFE TO BE ASSURED IN HIS OWN

HANDWRITING :
a) Have you ever been under medical treatment a)

for Glycosuria and, if so, when and for what
period ?
b) Have you had any occasion to take Insulin b)
injections, or ever been advised to restrict your
diet ? If so, give full details.
Dated at ………………………. On the …………………… day of ……………………200….
234
………………………………………. ………………………………………
Signature of the Life to be Assured Signature of the Pathologist
Qualifications……………………
SIGNED BEFORE ME
Name & Address …………………………………
(IN BLOCK LETTERS)
……………………………..
Signature of the Pathologist ………………………………………
235
OPTHALMIC REPORT
__________Division.
Proposal No.______________ Agent’s Name_____________________
Agent’s Code No.__________________
Name of the Life to be Assured :
Age :
Right Left
1. What is the presnt visual occuity for and near,
Naked eye and with glasses Without glasses
(State the strength of glasses) with glasses
2. What is the nature of the refraction ?
3. Hypermetropia, Myopia etc

If myopia, how long has he worn glasses?
Is the Myopia progressive or stationary?
4. Describe the condition of media.
5. Has be any cataract? If so which side?

Is it mature or not?
6. Are iris and pupil normal? If not describe the

Abnormality?
State pupillary reaction.
7. Is there any squint? If so paralytic or non paralytic
8. Did he have any occular operation? If so give details.
9. Is the funds normal? If not described in detail the

Abnormality and its significance.
Dated at on the day of 200
(SIGNATURE OF THE OPTHALMOLOGIST)
SIGNATURE OF THE LFIE TO BE ASSURED
QUALIFICATION
ADDRESS
236
Form No 3310
REPORT OF FLUOROSCOPIC EXAMINATION (SCREENING)
Proposal No………………………………. Agent’s Code No……………………..

Agent’s Name…………………………………………………………………………………………
INSTRUCTIONS
(1) The Fluoroscopic Examination should be done in the posterior-anterior and the
right and left oblique views.
(2) In Conclusion, please state whether you consider the condition of heart and lungs
to be quite normal.
________________________________________________________________________________
Full name of the Life to be Assured……………………………………………………………………..

Age…………………………..
(1) Lungs :
Movements……………………………………………………………………………………….
(Apices- Bases) Translucent Marking……………………………………………………………
Hilar shadow………………………………………………………………………………………
Phrenico-Costal angles…………………………………………………………………………….
Posterior-Mediastinum…………………………………………………………………………….
(2) Pleura:
Right………………………………………………………………………………………………
Left………………………………………………………………………………………………..
(3) Diaphragm :…………………………………………………………………………………..
(Right-Left) movements………………………………………………………………………….
Contour……………………………………………………………………………………………
(4) Heart :
Pulsations…………………………………………………………………………………………..
Position……………………………………………………………………………………………..
Size………………………………………………………………………………………………….
Pulmonary conus…………………………………………………………………………………...
(5) Aorta:
Size………………………………………………………………………………………………….
Density………………………………………………………………………………………………
(6) Bony Thorax :……………………………………………………………………………………
(7) Conclusions:
Dated at…………………………on the ………………….day of………………….20
…………………………………. ……………………………
Signature of the Life to be Assured Signature of the Medical Examiner
Signed before me Qualifications………………………

Code No……………………………
Name and Address…………………
……………………………………. (IN BLOCK LETTERS)
Medical Examiner
237
Form No. 3313
(Established by the Life Insurance Corporation Act, 1956)
_____________________________ DIVISION
REPORT ON X-RAY (PLAIN) OF GENITO URINARY TRACT

(N.B.: Take two Skiagrams: Kidneys, Ureters, Bladder and Prostate)
Proposal No. ________________________ Agent’s Code No.

Agent’s Name ____________________________________________________________________
(In Block Letters)
Name of the life to be assured

________________________________________________________________________
(In Block Letters)
Age. ________________________
(1) KIDNEYS :
Outlines _____________________________________________ Size _____Position
_____________________________________________ Calculi
Calcification :_________________________________________
Psoas Shadows:_________________________________________
(2) URETERS:
Calculi :___________________________________________________________
Calcification : ____________________________________________________
Phleboliths:________________________________________________________
(3) BLADDER: [Prostate (Male), uterus (Female) ]

Calculi__________________________________________________________________
Calcification_________________________________________________Phleboliths_____________
_________________________________________________
(4) ANY OTHER ABNORMALITIES :
CONCLUSIONS :
Dated at ______________ on the ______________ day of ______________ 200
238
………………………………….. …………………………………
Signature of the Life to be Assured Signature of the Radiologist
Qualifications
____________________________
Name & Address ____________
………………………… (IN BLOCK LETTERS)
Signature of the Radiologist ………………………….
…………………………
239
Form No 3314

REPORT ON X-RAY OF STOMACH & DUODENUM (BARIUM MEAL)
N.B. Take FIVE Films as follows:-
One Film Standing-Stomach and Duodenum.
Four Small Spot Films: Pyloro- Duodenal Servies.
Proposal No……………………………………………
Agent’s Name and Code No……………………………………………………………………
( IN BLOCK LETTERS )
Name of the Life to be Assured……………………………………….Age…………………..
Introduced by……………………………His Signature……………………………………….
1. Stomach :
Rugae of mucosal pattern…………………………………………………………………………
Position………………………………………. Size………………………………………………...
Contours…………………………………….. Niche……………………………………………
Filling defect……………………………….. Spasm…………………………………………..
Incisura……………………………………. Tenderness…………………………………….
Evacuation………………………………… Flexibility………………………………………
Patency of the pylorus…………………………………………………………………………….
2.Duodenum-Duodenal cap:
Size……………………………….. Position………………………………………………..
Regular or deformed…………….. Tenderness…………………………………………..
Peristalis or antiperistalis…………. Crater or niche…………………………………….
Residue……………………………………………………………………………………………….
3. Duodenal Canal beyond the cap:
Size………………………………… Position……………………………………………….
Crater……………………………… Spasm…………………………………………………
Irritability……………………………………………………………………………………………..
4. Conclusions:
Dated at……………………….on the………………day of……………………20
………………………………………. ………………………………………

Qualifications………………………..
Signed before me Name & Address…………………….
( IN BLOCK LETTERS)
…………………………………………
………………………………………….
Signature of the Radiologist
240
Form No. 3315
REPORT ON X-RAY OF CAECUM AND COLON (BARIUM ENEMA)
Proposal No………………………………………………………………………………….
Agent’s Name and Code No………………………………………………………………..

(In Block Letters)
Name of the life to be assured……………………………………..Age………………………

(In Block Letters)
Introduced by……………………………..His Signature………………………………………
Caecum and Colon (Barium Enema) :
Size and length………………………………………………………………………………………
Position………………………………………………………………………………………………..
Mobility………………………………………………………………………………………………..
Contours………………………………………………………………………………………………
Filling defect…………………………………………………………………………………………
Mucosal pattern…………………………………………………………………………………….
Peristasis………………………………………………………………………………………………
Naustra………………………………………………………………………………………………..
Tenderness……………………………………………………………………………………………
Any obstruction……………………………………………………………………………………...
Any palpable mass or diverticulosis……………………………………………………………
Any other abnormality…………………………………………………………………………….
………………………………………………………………………………………………………….
Conclusions :
_________________________________________________________________________________
Dated at……………………………..on the …………………..day of…………………20
……………………………….. ………………………………………
Signature of the Life to be Assured Signature of the Radiologist.
Signed before me Qualifications……………………

Name & Address…………………
(In Block Letters)
….……………………………………….
Signature of the Radiologist …………………………………………..
……………………………………….
241
Form No 3316
REPORT ON INTRAVENOUS-PYELOGRAPHY
N.B____(1) Take four Pyelograms as follows:-
1. Pyelograms-Kidneys & Ureters- 5 Minutes
4. Pyelogram – Bladder - 40 Minutes
(2) Before doing the intravenous pyelography plain skiagrams of the kidneys,
ureters, bladder and prostate should be taken, unless satisfactory skiagrams taken
previously within 3 months of the date of examination are available.
Proposal No………………………………………
Agent’s Name and Code No……………………………………………………………….
(In Block Letters)
Name of the life to be Assured………………………………………Age………………………

(In Block Letters)
Introduced by……………………………………His Signature…………………………………
1. Kidneys:
Function…………………………. Outlines………………………………………
Size………………………………… Position………………………………………
Calyces……………………………. Pelvis…………………………………………
Any other abnormality…………………………………………………………………………….
2.Ureters:
Position…………………………….. Obstruction………………………………….
Any other abnormality……………………………………………………………………………
3. Bladder:
Outlines……………………………… Filling defect………………………………….
Any other abnormality……………………………………………………………………………
4.Conclusions:
Dated………………..on the……………………day of ………………………….20
………………………………………. ……………………………………..
Qualifications…………………….
Name & Address………………..
(In Block Letters)
Signed before me
……………………………………
Signature of the Radiologist
…………………………………….
242
Form No 3317
Report on Cholecystography
Oral Method
N.B. :- Take five Skiagrams as follows :---
Skiagram 1. Plain gallbladder
,, 2. 15 to 16 minutes after dye-prone
,, 3. Standing
,, 4. 20 to 30 minutes after fatty meal
,, 5. 2 hours fatty meal
Proposal No ______________ Agents code no _____________
Agent’s name -------------------------------------------------------------------------------------------

( In Block Letters)
Name of the Life to be Assured ---------------------------------------------------------------------

( In Block Letters)
Age --------------
_____________________________________________________________________
1. Gall bladder :
Concentration---------------------- Size and Position ---------------------------------
Filling defect-----------------------------------------------------------------------------
Calculi (Radio-Opaque & Non- radio opaque) -------------------------------------
Calcification ----------------------------- Emptying -----------------------------------
2. Bile Ducts :
Size ------------------------------------- Stasis ---------------------------------------
Any Calculi -----------------------------------------------------------------------------
3. Screening :
Tenderness ----------------------------------------------------------------------------------
Mobility ------------------------------------------------------------------------------------
4. Any other abnormality:

_____________________________________________________________________
5. Conclusions :
_____________________________________________________________________
Dated at -------------------------- on the --------------------- day of -------------20----
……………………………………. …………………………………………
Signature of the life to be assured Signature of the Radiologist
243
Signed before me Qualifications……………………………
…………………………………….. Name and Address………………………

(IN BLOCK LETTERS)
Signature of the Radiologist …………………………………………...
…………………………………………...
244
Form No. 3321
EXAMINATION OF SPUTUM
Proposal No._______________________ Agent’s Code No.___________________

Agent’s Name ______________________
Name of the Life to be

Assured________________________________________________________________________
(IN BLOCK LETTERS)
Age___________________________
Quantity_________________________________Blood______________________Consistency_
_____________________
Reaction________________________Layer Formation___________________________
Cover Slip
Red Blood Cells___________________________Elastic Tissue ______________________
Pus Cells _________________________________
MORPHOLOGICAL EXAMINATION
(a) GRAM STAIN :-

(b) LEISHMAN STAIN (for eosinophilia) :-
Eosinophils_______________________________
(c) Z.N. METHOD : (direct & Concentration) :
Dated at ________________on this_________________day of_______________200
_____________________________________
245
Qualifications_________________________
_______________________________________ Code No
Signature of life to be assured
Name & Address________________________________
(In Block Letters)_______________________________
_____________________________________________
_____________________________________________
246
Form No 3335

REPORT ON EXAMINATION OF STOOL
Proposal No………………… Agent’s Name & Code No……………….
Name of the Life to be Assured…………………………Age………………………...

Specimen Examined:-
(i)Whether natural or passed after urine ……………… ii)Time…………………………….
Microscopic Examination
Colour………………………… Form and consistency…………………………...
Odour………………………… Mucus…………………………………………….
Blood (gross)…………………. Parasites…………………………………………
Intestinal sand……………….. Gall Stones………………………………………
Chemical Examination
Reaction………………… Bile……………………………………………...
Blood (Occult)………….. Stercobilin……………………………………...
Microscopial Examination
Ova……………………… Fat………………………………………………
Protozoa………………... Striped muscle fibres………………………….
Amoebae……………….. Starch (undigested)…………………………….
Flagellates……………… Vegetable fibres………………………………...
Erythrocytes…………… Crystals………………………………………...
Pus cells………………… Mucus cells……………………………………..
Leucocytes/ eosinophils…… Yeast……………………………………………
Macrophages……………….
Epithelium………………….
Concentration method for Ova

Ova…………………………………………………………………………………………
Z.N.Method………………………………………………………………………………..
Due Date………………………Time…………………..Disposal………………………..
Dated at…………………on the ………………….day of ………………….20…………
…………………………………….. ……………………………
Signature of the Life to be Assured Signature of the pathologist
Qualifications……………………….
Name and Address………………….
(IN BLOCK LETTERS)
……………………………………….
……………………………………….
N.B :- The pathologist should insist on the proposer signing on this form in his presence, A form on
which the proposer has already put his signature should not be used.
247
Form No.3338 (Revised 88)
SPECIAL BLOOD SUGAR TOLERANCE REPORT
Proposal No. Agent’s Name and

Code No.
Name of the Life to be Assured/Life Assured:
Age: Introduced by:
INSTRUCTIONS FOR THE PATHOLOGISTS

NB : (I) The observations should be made in the morning in the fasting sate and – 2 hours after
meals.
(ii) The pathologist should indicate the method of Blood Sugar Estimation employed and the
normal values.
(iii) Each column should be filled completely in every case.
(iv) Please insist on the proposer signing in your presence. A form on which the proposer
has already put his signature should not be used.
SAMPLE Time Blood Urine Acetone Normal
O’clock Sugar % Glucose % bodies value
Fasting
2 Hours after meals
INTERPRETATION________________________________________________________________
Please state the method of
Blood Sugar Estimation
employed__________________________________________________________
Queries to be answered by the Life to be Assured.
1. Time of taking of food on the day of the test
2. Details of food taken on the day of the test
Any medication – Name of the drug and its

dosage_______________________________________________________________
Dated at on this day of 200 .
………………………… ……………………………..
Signature of the Proposer Signature of the Pathologist
Qualifications………………………
Signed before me Name and Address…………………
Signature of the Pathologist
248
Form No 3341 (revised in February, 1997)
REPORT FROM GYNAECOLOGIST / ATTENDING GYNAECOLOGIST
The Gynaecologist completing this form is requested to satisfy himself / herself
(1) above the identity of the Life to be Assured and

(2) to obtain signature of the Life to be Assured on this form in him/her presence.
Proposal No. ……………………………………………………………………………………………
Agent’s Name & Code No.

…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
Full Name of the Examinee

…………………………………………………………………………………………………………...
Introduced by …………………His Signature …………………………………………………………
1. (a) Whether the Life to be Assured has any past 1. (a) Yes/No
history of abortion and/or miscarriage? If Yes, give full details including
cause/reasons thereof).
(b) Whether the Life to be Assured has previous (b) Yes/No
history of delivery by Caesarean Section (If Yes, give cause/reasons for
such Caesarean Section)
2. Whether there is any previous history of 2. If Yes, give full details

hysterectomy? Was any malignancy detected
3. Whether there is any previous history of any other 3. If yes, give full details.
Impairments generally associated with females?
4. Whether the Life to be Assured has previous history 4. If answer is yes, furnish full details
of Hypertension, Diabetes, Urinary Tract Infection, such diseases.
Cardiac or Pulmonary diseases?
5. What is the Blood Group – Rh factor ?
6. (a) Does your examination show that Life to be

Assured is pregnant?
249
(b) Does your examination reveal any sysptoms
Indicative of any abnormal pregnancy and/
Or expected delivery. If so, give details.
(c) What is your estimate is the approximate

Period of pregnancy ? (No. of weeks).
(d) Findings of the current Pathological &

Radiological examination (Done already for
The check-up)
i. Blood Group –Rh factor

ii. Blood Sugar (Post Prandial)
iii. Haemoglobin
iv. Urine – Albumin
v. Any other investigations
vi. Sonography of the Foetus
7. Does your examination indicate
(a) any disease of uterus, vagina or overies ?

(b) any weakness, injudy or sore resulting form
child-bearing or miscarriage?
If so give details.
Dated at on the day of 20.
Date:
………………………………….
Place: Signature of the Gynaecologist
Qualification……………………
Name & Address ………………………..
……………………………………………
Code no. / Reg No……………………………….
I hereby declare that the statements and answer given above are true and complete and I do
hereby agree and declare that these will form part of the proposal dated ……………….. given by me
to LIC of India.
Witness :
…………………………………………
…………………………………………. Signature of the Life to be Assured
250
ANNEXURE - I
LIFE INSURANCE CORPORATION OF INDIA F.No. LIC03 -001

(Established by the Life Insurance Corporation Act, 1956)
Branch No.
Proposal/Policy
MEDICAL EXAMINER’S CONFIDENTIAL REPORT No.
Medical Diary
No./Page No.
1. Full Name of the Life to be examined Case No. Month
Year
2. Age: Sex: Identification marks:
3. Introducer’s name & designation Introducer’s signature:
4. Height (cms) : Weight (kgs): Girth of abdomen (cms) (over

navel)
Chest (cms) Full Expiration (cms): Full inspiration (cms):

(over nipple):
Pulse Rate p.m. Blood Pressure Systolic Diastolic

1st reading
2nd reading
If answer/s to any of the following questions is ‘Yes’, please give full details and ask L.A.
to submit relevant documents with proposal form.
5. Ascertain from the L.A. whether at any time in the past he/she –
(a) was hospitalised.
(b) was operated.
(c) met with accident
(d) has undergone any bio-chemical, radiological, cardiological
or other test.
(e) is currently under any treatment.
6. Is there any abnormality observed on examination of Eyes (partial/total
blindness), Ears (deafness), Nose, Throat or Mouth or any physical
impairment.
7. Is there any externally visible swelling of lymph glands, joints or other
organs
8. Are there any symptoms and/or signs suggestive of abnormality of -
(a) Cardiovascular system
(b) Respiratory system
(c) central or peripheral nervous system
(d) Abdomen or pelvis
9. Is there evidence of enlargement of liver or spleen?
10. Is hernia present.
11. Is there any evidence of operation, if so state –
251
(a) Date of operation
(b) nature & cause
(c) Location, size & condition of scar
(d) degree of impairment
12. Is there any evidence of injury due to accident or otherwise –

(a) Date of injury
(b) Nature of injury
(c) Degree of impairment
(d) Duration of unconsciousness, if any.
13. Are there any other adverse features in habit or health, past or
present,
which you consider relevant, if so give details
14. For female only –
(a) Is there any disease of breasts
(b) Do you suspect any disease of uterus, cervix or ovaries
(c) Is there any evidence of pregnancy, if so give duration.
15. On examination whether he / she appears healthy.
I hereby certify that I have, this day, examined the above life to be assured personally, in private, and
recorded in my own hand (i) the true and correct findings (ii) the answers to Question No.5 as
ascertained from the person examined.
I declare that the person examined signed (affixed his/her thumb impression) in the space
earmarked below, in my presence and that I am not related to him/her or the Agent or the
Development Officer.
Dated at on the day of 200 at a.m. / p.m.
Signature of the L.A. Signature of the Medical Examiner

Name & Address………………………………….
Qualification …………………………………..
Code: ………………………………….
Limit : ………………………………….
252
JUVENILE FMR
Zone Division Branch
Proposal No.
Agent/D.O. Code: Introduced by: (name & signature)
Name of the child: (Master/ Miss)

Mark of identification: Mole/Scar/any other (specify location)
Current ID Student Passport Latest School Report Card Others(specify)
provided
Age of the child: ___________Years/Months SEX: M / F
Birth History: FTND / Forceps / Caesarean/ Other ( Please tick the relevant)
A. Details of Physical Examination

For all children:
Height of the child: _______ cms Weight of the child: _____ kgs
Pulse and character __________ Blood Pressure __________ mm of Hg
Presence of any congenital defects or abnormalities: Yes / No
( If yes, please provide details)
For Children Below 2 yrs:

Head Circumference ___________ cms Chest Circumference ___________ cms
B. Medical History:
1) Is the proposed insured presently in good health? Yes / No
2) Does the proposed insured have any physical and Yes / No If yes provide
mental details:
handicap or deformity?
3) Has the proposed insured been hospitalized and/or Yes / No If yes provide details
has of the tests conducted and treatment
been advised for any treatment/surgery and/or has if any.
undergone any general checkup in the last five years?
4) Has the proposed insured ever been treated or Yes / No If yes provide
hospitalized details:
for any Heart ailment/cancer/ kidney disorder/
epilepsy/ mental disorder/ diabetes/ musculoskeletal
disorder/ blood disorder/ respiratory disorder like
Bronchitis or Asthma/congenital or hereditary
disorder
5) Is the child’s behavior / appearance / mental ability Yes / No If yes provide
in line details:
with his current age?
6) If school going, has proposed insured taken any sick Yes / No If yes provide
leave details:
from school in the last 2 years?
7) Please give details of proposed insured’s family Father:
253
history : Mother :
Is any family member/s either suffering or have Sibling 1
suffered or have died from heart disease, Sibling 2
thallassaemia, cancer, kidney disease, any other
hereditary / familial disorders
C. Immunization History: (Mandatory for ages < and equal to 5 yrs)

Vaccinated for
1. OPV: Yes / 2. DPT: Yes / No
No
3. BCG: Yes / 4. Hepatitis B: Yes / No
No
5. Mumps, Measles, Rubella: Yes / 6. Typhoid (above 1 Yr): Yes / No
No
7. Hepatitis A ( Above 1 Yr) : Yes /
No
D. Medical Examination
Do you find any evidence of abnormality, disease or surgery of: If yes please elaborate
1) the respiratory system? Yes No
2) the central and peripheral nervous system? Yes No
3) the genito urinary system? Yes No
4) the abdominal organs? Yes No
5) the head, face, mouth, throat, eyes, ears Yes No
,nose and neck?
6) the skin, muscles, bones and joints? Yes No
7) The Cardiovascular system:
a) Are the peripheral pulses normal? Yes No
b) Is there any evidence of heart Yes No
enlargement?
c) Are there murmurs or abnormal heart Yes No
sounds?
d) Do you suspect any abnormality of the Yes No
cardiovascular system?
Declaration by the parent accompanying the child:
I hereby confirm that all facts regarding the child as recorded by the doctor are true and complete.
Signature of the parent: ______________ Name of the parent ____________________________
Doctor’s Declaration
• I hereby confirm that I have, this day, examined the above individual personally, in private
and recorded the above information in my own handwriting. I certify that I have personally
recorded the history as informed by the examinee/parent accompanying the child.
254
• Place of Examination: Clinic Examinee’s Residence
• I declare that the examinee has signed/affixed his/her thumb impression in my presence.
Dated at _____________on the __________day of_________ 200 at a.m./p.m.
_______________________ ___________________________
Signature / thumb impression Signature of the Medical Examiner
of the examinee Name & Address
Qualification
Code:
Limit
_________________________________________________________________________________
Confidential Comments from Doctor
Are there any points on which you suggest further information be obtained? YES NO

• For physical investigations
• For mental level assessment

_____________________________________________________________________
255
ANNEXURE II - 1
Form No. LIC03 - 002
ELECTROCARDIOGRAM
Proposal No.
Full Name of Life to be assured:
Age/Sex :
Instructions to the Cardiologist:
i. Please satisfy yourself about the identity of the examiners to guard against
impersonation
ii. The examinee and the person introducing him must sign in your presence.
Do not use the form signed in advance. Also obtain signatures on ECG tracings.
iii. The base line must be steady. The tracing must be pasted on a folder.
iv. Rest ECG should be 12 leads along with Standardization slip, each lead with
minimum of 3 complexes, long lead II. If L-III and AVF shows deep Q or T wave change,
they should be recorded additionally in deep inspiration. If V1 shows a tall R-Wave,
additional lead V4R be recorded.
DECLARATION
I hereby declare that the foregoing answers are given by me after fully understanding the questions.
They are true and complete and no information has been withheld. I do agree that these will form
part of the proposal dated _____ given by me to LIC of India.
Witness Signature or Thumb Impression of L.A.
Note : Cardiologist is requested to explain following questions to L.A. and to note the answers
thereof.
i. Have you ever had chest pain, palpitation, breathlessness at rest or exertion?
Y/N .
ii. Are you suffering from heart disease, diabetes, high or low Blood Pressure or kidney
disease? Y/N .
256
iii. Have you ever had Chest X- Ray, ECG, Blood Sugar, Cholesterol or any other test
done? Y/N .
If the answer/s to any/all above questions is ‘Yes’, submit all relevant papers with this form.

Signature of the Cardiologist
Signature of L.A. Name & Address
Qualification Code No.
257
2
Clinical findings
(A)
Height (Cms) Weight (kgs) Blood Pressure Pulse Rate
(B) Cardiovascular System

………………………………………………………………………………………
………………………………………………………………………………………
Rest ECG Report:
Position P Wave
Standardisation Imv PR Interval
Mechanism QRS Complexes
Voltage Q-T Duration
Electrical Axis S-T Segment
Auricular Rate T –wave
Ventricular Rate Q-Wave
Rhythm
Additional findings, if any.
Conclusion:
258

Name & Address
Qualification
Code No.
259
ANNEXURE II - 2
COMPUTERISED TREADMILL TEST

Form No. LIC 03 - 003
Proposal No.
Age/Sex:
DECLARATION
I hereby declare that the foregoing answers are given by me after fully understanding the questions.
They are true and complete and no information has been withheld. I do agree that these will form
part of the proposal dated _____ given by me to LIC of India.
Witness Signature or Thumb Impression of L.A.
Note : Cardiologist is requested to explain following questions to L.A. and to note the answers
thereof.
1. Have you ever had chest pain, palpitation, breathlessness at rest or exertion? Y/N
2. Are you suffering from heart disease, diabetes, high or low Blood Pressure or kidney
disease? Y/N
3. Have you ever had Chest X-Ray, ECG, Blood Sugar, Cholesterol or any other test done?
Y/N
If the answer/s to any/all above questions ‘Yes’, submit all relevant papers with this form.
260
Signature of L.A. Name & Address
Qualification
Code No.
(a) Pre-test : Supine

Standing
Hyperventilation
(b) Exercise: Stage I )
Stage II ) 3 minutes each
Stage III )
… peak exercise
(c) Recovery: Recovery
Recovery
Recovery
Reporting Pattern
Phase Name Stage Name Time Speed Grade Workload HR BP RPP

in (mph) (%) (METS) (bpm) (mmHg)
Stage
SUPINE
PRETEST SITTING
STANDING
HYPERVENTILATION
WARM UP
STAGE 1
EXERCISE STAGE 2
STAGE 3
PEAK EXERCISE
RECOVERY
RECOVERY RECOVERY
RECOVERY
261
The protocol used - BRUCE
Total Exercise Time -
Maximum Blood Pressure –
Maximum Workload -
Maximum heart rate Maximum predicted heart rate %
Reason for termination –
Comments:

Name & Address
Qualification Code No.
Each stage should have 12 lead tracing with long lead II. Each lead should contain atleast three
complexes. On separate individual paper each stage with relevant observations be recorded.
(Signature of the L.A. to be obtained on the tracings)
262
ANNEXURE II - 3
Special Medical Report

HAEMOGRAM

Proposal No.
Agent/D.O. Code: Introduced by : (name & signature)
Age/Sex :
1. Red Blood Cell Count :

2. Hb% :
3. Hematocrit :
4. Indices :
(a) MCV (Mean Corpuscular Volume)
(b) MCH (Mean Corpuscular Hb)
(c) MCHC (Mean Corpuscular Hb Concentration)
5. Morphology
Macrocytes: Microcytes: Hypochromia:
Poikilocytosis: Anisocytosis:
6. Target Cells
Spherocytes: Eliptocytes:
7. White Blood Cells

Total Count:
Differential Count :
a) Neutrophils: c) Eosinophils:
263
b) Lymphocytes: d) Monocytes:
e) Basophils:
8. Platelets:
9. Erythrocytes Sedimentation rate:

(Method )
I declare that the person examined signed (affixed his/her thumb impression) in the space earmarked
below, in my presence and I am not related to him/her or the Agent or the Development Officer.
Dated at on the day of 200 at a.m./p.m.
Signature of the L.A. Signature of the

pathologist
Pathologist’s name
Qualification :
LICI Code No. :
264
ANNEXURE II - 4

LIPIDOGRAM

Proposal No.
Agent/D.O. Code : Introduced by : (name & signature)
Age/Sex :
Type of Test Actual Reading

1 Total Cholesterol
2 High Density Lipid (HDL)
Low Density Lipid (LDL)
3 S. Triglycerides
Signature of the L.A. Signature of the Pathologist
Pathologist’s name & Address
Qualification:
LICI Code No:
265
ANNEXURE II - 5

BLOOD SUGAR TOLERANCE REPORT

Proposal No.
Agent/D.O. Code : Introduced by : (name & signature)
Age/Sex :
INSTRUCTIONS FOR THE PATHOLOGIST
• The observations should be made in the morning in the fasting state before and after the
ingestion of 75 grams of glucose
• The pathologist should indicate the method of blood estimation employed and the normal
values
• Each column should be filled in every case
• Please insist on the proposer signing in your presence. A form on which the proposer has
already put his signature should not be used.
Sample O’Clock Blood Sugar Urine Acetone Normal

% Glucose % Bodies Value
Fasting
2 Hours
after 75 gms
of Glucose
Interpretation
266
Method of blood sugar estimation employed
Qualification:
LICI Code No:
267
ANNEXURE II – 6

SPECIAL BIO-CHEMICAL TESTS – 12 (SBT-12)

Proposal No.
Age/Sex :
1 Blood Sugar (Method____________________)

Fasting
Post Glucose (75 gms of Glucose) / Post Lunch
2 Total Cholesterol
3 S. Triglycerides
4 S. Creatinine
5 Uric Acid
6 S. Proteins
(a) Albumin
(b) Globulin
(c) AG Ratio
7 S.Bilirubin
(a) Direct
(b) Indirect
(c) Total
8 SGOT (AST)
9 SGPT (ALT)
268
10 S. Alkaline Phosphatase
11 S. Electrolytes
12 Elisa for HIV
(Method_______________________)
Qualification:
LICI Code No:
269
ANNEXURE II – 7

SPECIAL BIO-CHEMICAL TESTS – 18 (SBT-18)

Proposal No.
Age/Sex :

1 Blood Sugar (Method )
Fasting
Post Glucose (75 gm of Glucose) / Post Lunch
2 Total Cholesterol
3 S. Triglycerides
4 S. Creatinine
5 Blood Urea Nitrogen (BUN)
6 Uric Acid
7 S. Proteins
(a) Albumin
(b) Globulin
(c) AG Ratio
8 S.Bilirubin
(a) Direct
(b) Indirect
(c) Total
9 SGOT (AST)
270
10 SGPT (ALT)
11 GGTP (GGT)
12 S. Alkaline Phosphatase
13 S. Electrolytes
14 HBSAg (Australian Antigen)
15 VDRL
16 S. Amylase
17 Acid Phosphates
18 Elisa for HIV
(Method_______________________)

Pathologist’s name & Address Qualification: LICI Code No:
271
ANNEXURE II - 8
ROUTINE URINE ANALYSIS

Proposal No.
Age/Sex :
1. Physical Examination
(i) Colour (ii) Sediment
(iii) Transparency (iv) Reaction
2. Chemical Examination
(i) Protein (ii) Sugar
(iii) Bile salt (iv) Bile pigments
3. Microscopic Examination
(i) Red Blood Cells (ii) Epithelial Cells
(iii) Crystals (iv) Pus Cells
(v) Casts (vi) Deposits
(Bacterias )
Remarks
If pus cells are present GRAM STAIN is necessary
If haematuria is present ZIEHL NEELSEN METHOD is necessary
272
I declare that the person (investigated) signed (affixed his/her thumb impression) in the space
earmarked below, in my presence and that I am not related to him/her or the Agent of the
Development Officer.

Qualification :
LICI Code No. :
273
ANNEXURE II – 9

REPORT ON X-RAY OF CHEST (P.A. VIEW)

Proposal No.
Age/Sex :
Instructions to Radiologist:
a. Film-focus distance should be 72 inches
b. Exposure time should not be longer than 1/10th second
c. The x-ray plate should be taken in the vertical position of the patient in deep
inspiration
d. The x-ray plate must bear name of the proposer, your initials and date.
Report:
1. Condition of Lungs and Pleura (Full details of abnormality if any should be given)
2. Heart and Aorta
a. Transverse diameter of heart
b. Transverse diameter of Aortic Arch
c. Cardio-thoracic Ratio
d. Any changes, such as Arteriosclerotic changes and calcification of aorta etc.
3. Conclusions
I declare that the person (investigated) signed (affixed his/her thumb impression) in the space
earmarked below, in my presence and that I am not related to him/her or the Agent or the Development
Officer.
274
Signature of the L.A. Signature of the Radiologist
Name & Address
Qualification :
LICI Code No. :
275
ANNEXURE II – 10
ELISA FOR HIV

Proposal No.
Age/Sex :
EXAMINATION OF BLOOD FOR HIV I & II TEST
HIV I & II :
RESULT :
Method :
Pathologist’s name & Address Qualification: LICI Code No:
276
ANNEXURE II - 11
PHYSICIAN’S REPORT
DECLARATION
I, hereby authorise Dr ________________ to intimate LIC of India all necessary information about
my health obtained on history, examination including diagnosis and treatment.
I hereby declare that the statements and answers to Questions in Part One and Part Two of this report
are true and complete and I do hereby declare that these will form part of the proposal dated _____
given by me to LIC of India.
Signature of the L.A.

PART – I.
1. Full Name of Life to be assured (L.A.)

2. Has the L.A. suffered from –
Heart Disease Hypertension Diabetes

Y/N Y/N Y/N
(If yes, state name, address of the Consultant and submit all relevant papers with this form)
3. Does L.A. consume tobacco, snuff, other narcotic substances in any form ?
No. of Years Quantity used Date of cessation, if any
4. Does L.A. consume alcoholic drinks?
No. of Years Quantity used Date of cessation, if any
277
Signature of Physician
Date: Name:
Qualification:
Reg.No.
Note : If Q.2 of Part-I is negative, no need of filling up Part-II.
278
PART – II.
1. Is L.A. ever treated / hospitalised for any heart disease, hypertension, and diabetes?
Y/N *
(If ‘Yes’ then details of –
Investigations Treatment Hospitalisation Present status Prognosis
2. Blood Pressure Reading -
Current At the time of detection of HT Duration of HT, if taking

regular treatment
3. Diabetes -
Date of Diagnosis Type Duration
4. Are there any symptoms/signs of
(a) Renal Disease
279
(b) Neurological involvement
(c) Eye Involvement
(d) Peripheral Vascular Disease
(e) Any other infectious diseases (esp. TB)
5. Is L.A. taking regular treatment for above disease/s?
* (enclose all relevant papers with this form)
Signature of the L.A. Signature of Physician

Date: Name:
Qualification :
Reg.No.
280
MISCELLANEOUS FORMS
281
Form No. 400.

(Established by the Life Insurance Act 1956)
_____________________Division.
(Additional form to be completed by the proposers under a Joint Life policy)
Branch Office Agents Code No.
Agent’s Name Proposal No.
We the undersigned, who desire to effect Policy under the joint Life Endowment Assurance
Plan of the Corporation for the sum of Rs……………………………… hereby jointly and severally
confirm the satements made in our respective proposals for Assurance
dated…………………………………………and
…………………………………………………………………….and the replies to questions in our
respective personal statements given before the Medical Examiner(s) on the
……………………………and ………………………..respectively, and we hereby jointly and
severally declare that all such statements and replies are true and accept joint responsibility in respect
thereon. We further hereby jointly and severally declare that the said several statements and answers
in the said documents 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 absolutely be null and void and all moneys which shall have been paid in respect thereof shall
stand forfeited to the Corporation.
Dated at……………………………on the…………………..day of……………..200 .
Name of Witness………………………………..
Signature of
Witness………………………………………….
Occupation……………………………………..
(1)………………………………………..
Address…………………………………………
………………………………………………….
(2)……………………………………….
Sig. Of proposers.
“If the answers to questions in this form are given in vernacular or if the answers to the questions are
given in English but either one or more of the proposers sign in vernacular then the proposer(s) would
declare in his/her/their own handwriting above his/her/their respective signature(s) that all questions
were explained to him/her/them and that his/her/their replies were given after fully and properly
understanding the same.”
282
Form No. 3111

BRANCH OFFICE……………
Ref.: ................................. Date ..........................
Dear Sir/Madam,
Re : Proposal No. Own Life.
We are in receipt of your proposal for Rs.........................under Plan and Term............ and
while thanking you for the same, we have to inform you that we are prepared to accept it
...................................................................................................................................................................
......................................................................................................................................................for age
........................years.........................and the............................yearly premium comes to Rs...............P.
We shall now thank you to furnish us the following requirement/s numbered........................to enable
us to proceed further :-
1. A sum of Rs..............................P. being the First Premium/being the difference
between the First Premium and the amount paid by you as deposit.
2. Your consent on the enclosed form to the terms of acceptance stated above with a
declaration in your own handwriting that the contents have been understood by you, if
the letter is signed in a language other than English.
3. Authentic evidence satisfactory to the Corporation in proof of your age.
4. Your age is admitted/is not admitted. If the premium to be paid out of your account
with the Regional Provident Fund, you are requested to submit an authentic evidence
in proof of age, for unless your age is admitted the Regional Provident Fund
Commissioner may not permit payment of the premium out of the Provident Fund.
5. An amount of Rs....................P.............being the interest at 8% on the premium for
dating back the Policy to .........................................
6. Declaration of good health on your life on the enclosed form.
If the requirements mentioned above are not received within ................days from the date of
this letter, evidence of your continued good health may have to be produced at your expense.
Since you desire to pay the premiums from your Provident Fund, we are enclosing an extra
copy of this letter for your record. The original may be forwarded to the Authorities of your
Provident Fund to enable them to make necessary arrangements for payment of the Premium. This
payment should be remitted to our Branch Office at the following address :-
Assuring you of our best services

Yours faithfully,
Encl:
283
Form No 3112
Servicing Branch Address:

FIRST PREMIUM RECEIPT
Branch Office Policy No
Policy Short Name Due Premiu Particulars

Number Plan Date m of terms
Date of Sum Assured Mode of
risk acceptanc
Instalment e if not as
proposed
Annual
Acc.Premiu
m
How
Accepted
Clause Nos
Nominee
and
Proposal
Date
Date of
birth
Date of
maturity
Date of last
payment
Age &
whether
admitted
Dear Sir / Madam,

Your proposal for Assurance as per particulars noted in the schedule has been accepted by the
Corporation as proposed at ordinary rates/with AB & DB. We have also received the amount noted in
the schedule being the First premium on the policy assurance for the plan and amount indicated there
in. The acceptance of the payment places the Corporation on risk with effect from date of this
Acceptance - cum - First Premium Receipt or if the Proposal is under the Children Deferred
Assurance Plan from the deferred date on terms & conditions of the Policy of assurance which will be
sent shortly. The issue of this receipt is also subject to the realisation of the amount in Cash and the
terms and conditions of acceptance printed overleaf.
Additional Premium of Rs.___________________________________________
due _____________________________________________also adjusted
Balance held in Deposit Rs.___________________________
p.Sr Branch Manager
284
Next Premium falls Due
Prepared by
TERMS & CONDITIONS OF ACCEPTANCE
Important to note that if any change in your occupation or any adverse circumstances connected with
your financial position or general health of yourself or that of your family however unimportant you
may consider the same occurs between the date of this proposal and the date of issue of this receipt
this assurance will be invalid and all moneys which shall have been paid in respect thereof forfeited
unless intimation of such event be made in writing to the Corporation and this acceptance of proposal
be reapproved by the Corporation.
IF YOU DO NOT RECEIVE POLICY WITHIN TWO MONTHS PLEASE WRITE TO THE
CONCERNED BRANCH OFFICE MEANWHILE PLEASE PAY THE NEXT PREMIUM WHEN
DUE.
P.T.O.
Dear Policy holder,
We thank you for your wise decision of taking Insurance Policy with us. This insurance cover is very
valuable not only to you but also to your family for whose benefit the policy is taken. Please,
therefore, keep the policy document when received, in safe custody. Kindly note to remit premia
regularly.
It is ESSENTIAL for you inform the change of your address to be in receipt of BONUS
INTIMATIONS promptly.
YOU MAY FEEL FREE EITHER TO WRITE TO US OR TO CONTACT OUR L.I.C. AGENT
FOR ANY SERVICING YOU MAY REQUIRE.
FOR SSS POLICY HOLDERS

As desired by you, the monthly premium under the policy is to be deducted from your pay roll.
Please ENSURE that the deduction of premium from your salary is carried out by your office. You
are REQUESTED to see that the correct policy number is mentioned in the Challan/Invoice prepared
by your office and sent to L.I.C. Branch.
For any problem with regard to your policy, you may please approach the nearest Branch of LIC
which renders service to the policies of your other colleagues. You may ascertain the name of the
LIC Branch Office, either from any of our offices or the LIC Agent.
We are sure that you will extend your full cooperation to enable us not to ensure prompt receipt of the
premia on the policy but also to adjust the same to enhance the efficiency of our services to you.
It is likely that your services may be required by your organisaton at other offices as well, either on
transfer or on deputation. It is, therefore, necessary to make sure that the monthly premium under the
policy is regularly deducted under correct policy number by the office where you are transferred or
sent on deputation and the Branch Office of LIC servicing the policy holders of the respective area
should be informed of the change. This is ABSOLUTELY NECESSARY IN YOUR OWN
INTEREST.
It is DESIRABLE you ASCERTAIN your POLICY STATUS once in three years by writing to our
office servicing your policy.
Please NOTE that remittance of premia should not be made directly. PAYMENTS SHOULD COME
THROUGH THE P.A. CONCERNED ONLY. THAT TOO IN THE APPROVED MANNER
ONLY.
WHEN TRANSFERRED MAKE SURE YOUR POLICY RECORDS AND ACCOUNTS ARE
TRANSFERRED JUST LIKE YOUR S.B. ACCOUNT AND GAS CONNECTION ETC.
285
Form No.3166
Policy Extract from Previous Policy / Proposal Papers
Divisional office /Branch Office Policy No/ Corresponding Proposal No

Name Sum Assured
Father’s Name Description of Plan
Occupation Term
Age Date of Birth Other assurances mentioned in the proposal
Whether age admitted Insurer Pol./Prop Sum Year

No Assured
Proof of age
Medical Examiner Date of examination
Qualifications Limit: Place of examination
Height Pulse Other particulars, If Adverse.

Weight Systolic BP Any special report received,
Chest on inspiration Diastolic BP If so, declare
Chest on expiration
Abdomen
Family History If living If dead
Age State of health Cause of Year of Duration Age at
death death of illness death
Father
Mother
Brothers
Sisters
Wife/Husband
Children No of living No Dead Cause and years of death
How proposal was decided Certified Extract,

Whether by BO/DO/ZUS/CUS Decision and date
Whether policy is in full force
If not, the due date of last premium paid and mode
p. Sr / BM.
286
Form No 3233
FROM:
------------------------------------------------------------------------
-----------------------------------
(Name of the Assignor in Block Letters)

To,
The Senior/Branch -Manager,
Life Insurance Corporation of India.
-------------------------------------------------
……………………………………………..
Dear Sir,
Re : Policy No. ______________________________
Please take notice that I have assigned the above Policy to_____________________
_________________________________ on ________________________which I send
herewith.
I shall thank you to register the assignment in your Books and to send me a written, acknow-
ledgement of the notice hereby given to you. Please forward the Policy after registration of the
Assignment o________________________________________________
A copy of assignment is also enclosed herewith for your records.
(Notice should be given by the Assignor or his / her duly authorized agent.)
Encl: Yours faithfully,
(Signature of the Assignor.)
A copy of assignment is also enclosed herewith for your records.
(Notice should be given by the Assignor or his/her duly authorised agent.)
Encl: Yours faithfully,
(Signature of the assignor)
287
Form No 3237
FORM OF NOMINATION UNDER A JOINT LIFE POLICY
We,…………………………………………………………………………… ………………….
. . ………………………………………………………………………………………………….the
joint lives assured under the within Policy do hereby nominate our.. . ... . ... . ………... .... ..... . . . . . .
................................................................Aged................. years to be the person to whom the moneys
secured by the within Policy would be paid in the event of our simultaneous death in any common
calamity when it shall be impossible to prove which of us survived the other.
Dated at... . . . . . . ... .... ... . . . . on the... . . . . . . . . ... . . ........day of .................
(Signature of the lives Assured)
Signature of witness:…………………………………………
Occupation :……………………………
Address :……………………………….
.........................
Please see on the reverse for insructions)
INSTRUCTIONS
(1) A nomination can be made only by the holders of a Policy on their own lives, i.e. only by the
lives assured.
(2) After filling up the blanks as may be necessary in the Form of Nomination, printed on the
reverse, the Lives Assured should copy it out on the back of the Policy.
(3) The Lives Assured must affix their signatures to the endorsement in the presence of a witness.
If one or both the Lives Assured be not conversant with English, he/she/they should sign the
endorsement before an English knowing witness and if he/she/they be illiterate, he/she/they
must affix his/her/their thumb impression(s) to the endorsement before a Magistrate, Justice
of the Peace or Gazetted Officer. In such cases the witness should certify as follows:
“Certified that the contents of the above nomination have been explained by me to the
life/lives assured……….in vernacular and that h/she/they affixed their signature (s) thumb/
impression(s) thereto in my presence, after his/her/their thoroughly understanding the same.”
(4) Immediately after a nomination has been effected by an endorsement, the policy must be sent
to the Office of the Corporation for registration of the nomination. A Nomination will NOT be
effectual unless it is communicated to and registered by the Corporation.
(5) If the nominee be a minor, it is advisable to appoint in the manner prescribed by the Insurance
Act an
appointee to receive the moneys secured by the Policy in the event of the simultaneous death
of the lives assured etc: during the minority of the nominee. A form of appointment of
Appointee with instructions can be had from the Corporation on application.
288
Form No 3237 A

FORM OF NOMINATION UNDER JEEVAN SATHI POLICY
We, ……………………………the lives assured under the within policy, hereby nominate under
Section 39 of the Insurance Act, 1938 our (relationship)……………named
……………………………aged………….years and whose address is …………………………as the
person to whom the moneys secured by the within policy shall be paid in the event of death of both of
us either simultaneously or one after the other at any time before the date of maturity under the within
policy.
Dated at ……………….on the ……………day of …………20
1…………………………………..
2…………………………………...
(Signatures of lives assured)
Signature of witness………………………….. Certified that the contents of the nomination

Full Name……………………………………. Have been explained by me to the life/lives
Designation…………………………………. Assured…………….in vernacular and that
Address…………………………………….. he/she/ they affixed their signature(s) thumb
impression(s) thereto in my presence after
His/her/their thoroughly understanding the
same”
SEAL
…………………………………………….
Signature of witness
INSTRUCTIONS
(1) A nomination can be made only by the holders of a Policy on their own lives, i.e., only by the
Lives Assured.
(2) After filling up the blanks as may be necessary in the Form of Nomination, printed on the
reverse, the Lives Assured should copy it out on the back of the Policy.
(3) The Lives Assured must affix their signatures to the endorsement in the presence of a witness.
If one or both the Lives Assured be not conversant with English, he/she/they should sign the
endorsement before an English knowing witness and if he/she/they be illiterate, he/she/they
must affix his/her/their thumb impression(s) to the endorsement before a Magistrate, Justice of
the Peace or Gazetted Officer. In such cases the witness should certify as follows :
"Certified that the contents of the above nomination have been explained by me to the life/lives
assured............ in vernacular and that he/she/they affixed their signature(s) thumb/impression(s)
thereto in my presence, after his/her/their thoroughly uderstanding the same."
289
(4) Immediately after a nomination has been effected by an endorsement, the Policy must be sent
to the Divisional Office of the Corporation for registration of the nomination. A Nomination
will NOT be effectual unless it is communicated to and registered by the Corporation.
(5) If the nominee be a minor, it is advisable to appoint in the manner prescribed by the Insurance
Act an appointee to receive the moneys secured by the Policy in the event of the simultaneous
death of the lives assured etc., during the minority of the nominee. A form of appointment of
Appointee with instructions can be had from the Corporation on application.
290
Form No 3248
Date……………………………..
Policy holder
…………………………………
…………………………………
Dear Sir,
Re: Policy No……………………………. Own Life
Your above policy was sent by registered book post on…………………………at the
address given by you in the proposal form. However the policy has been returned back by the postal
authorities with the remarks
as”…………………………………………………………………………………………………
You are requested to make the necessary arrangements to collect the policy from the
postal authorities without fail.
Kindly also intimate to us your changed address, if any change has taken place in your
address.
Yours faithfully,
p. Sr / Branch Manager.
291
FORM NO 3264
FORM OF NOMINATION
I _____________________________________ THE ASSURED UNDER THE WITHIN

Policy, hereby nominate under Section 39 of the Insurance Act, 1938, my, (relationship)
________________________________named _________________________________
age _______ years and whose address is
________________________________________
________________________________________________________________________
__as the person to whom the moneys secured under the Policy shall be paid in the event
of my death.
Signed at ___________________ this ________________ day of ___________ 200 __
______________________
Signature of Life Assured
Witness :
(Signature in English)
Full Name ____________________________________________
Designation _____________________________________________
Address _____________________________________________
_____________________________________________
(Please turn over for instructions)
292
INSTRUCTIONS
1. A nomination can be made only by the holder of a policy on his own life, i.e., by
the Life Assured.
2. After filing up the blanks as may be necessary in the form of Nomination, printed
on the reverse, the Assured should copy it out on the back of the Policy.
3. The Assured must affix his signature to the endorsement in the presence of a
witness. If the Assured be not conversant with English, he should sign the
endorsement before an English knowing witness and if he be illiterate he must
affix his thumb impression to the endorsement before a Magistrate, Justice of the
Peace, Gazetted Officer, an Officer of the Corporation or Development Officer of
at least 3 years standing or confirmed Development Officers recruited from the
Agents who were DM’s Club Members before joining or Development Officers
recruited from the agents who were ZM or Chairman’s club members provided
he/she is fully satisfied about the identity of the person(s) executing the
endorsement. In such cases the witness should certify as follows :
Certified that the contents of the above nomination have been explained by me to
the Assured _____________________________________ in Hindi or any other
Indian Language and that he affixed his signature / thumb impression there to in
my presence, after thoroughly understanding the same”
4. Immediately after a nomination has been effected by an endorsement the Policy

must be sent to the Branch Office of the Corporation where it is being serviced for
registration of the Nomination. A nomination will not be effectual unless it is
communicated to and registered by the Corporation.
5. If the Nominee be a minor it is advisable to appoint in the manner prescribed by

the Insurance Act, an Appointee receive the moneys secured by the Policy in the
event of the Assured’s death during minority of the Nominee. A form of
Appointment of Appointee with instructions can be had from the Corporation on
application.
293
FORM NO. 3265
FORM OF NOMINATION
(For Minor Nominee)
I, ………………………………………………………………………………………. the
life assured under the Policy No. ……………………………. Hereby nominate my
(relationship) ………………………… named ……………… aged …………… years,
whose address is ………………………………………………..
………………………………………………………………………………………………
… to whom the moneys secured under this policy shall be paid in the event of my death,
and I hereby appoint ……………………………………………………………........ aged
………………………… years and whose address is
…………………………………………………………………………………………. as
the person to receive the moneys secured by this Policy in the event of my death during
the minority of the nominee.
Signed at ………………………….. this …………………… day of
…………………..200…….
Witness :
Signature ……………………………..
Full Name ……………………………..
Occupation ……………………………..
Address ……………………………..
…………………………………………………
……………………………………
Signature of the Life Assured
I, the above named
………………………………………………………………….. (Appointee) do hereby
endorse my consent to my appointment aforesaid.
Witness :
294
Signature ……………………………..
Full Name ……………………………..
Occupation ……………………………..
Address ……………………………..
…………………………………………
Signature of the Appointee
( Please see instructions on next page)
INSTRUCTIONS
1. An Appointment of Appointee can be made only by the holder of a Policy on his

own life, i.e., only by the Life Assured.
2. After filling up the blanks as may be necessary in the form of the Appointment of
Appointee, printed on the reverse, the Life Assured should copy it out on the
back of the Policy.
3. The Life Assured must affix his signature to the endorsement of Appointment of
Appointee in the presence of a witness if the Life Assured be not conversant with
English, he should sign the endorsement before an English knowing witness and
if he be illiterate he must affix his thumb impression to the endorsement before a
Magistrate, Justice of the Peace or Gazetted Officer, an Officer of LIC or
Development Officer at least 3 years standing or confirmed Development Officers
recruited from the Agents who were the DM or BM Club Members before joining
or Development Officers recruited from the agents who were ZM or CM club
members provided he/she is fully satisfied about the identity of the person
executing the endorsement. In such cases the witness should certify as follows :
“ Certified that the contents of the above Appointment of Appointee have been
explained by me to the Life Assured Mr.
_____________________________________ in vernacular and that he affixed
his signature / thumb impression there to in my presence, after thoroughly
understanding the same”.
Signature of Witness (Seal)
4. The Appointee must also affix his signature below the endorsement of
Appointment of Appointee in token of his consent thereto before a witness who
should attest the same.
295
5. An Appointment of Appointee will not be effected unless it is communicated to
and registered by the Corporation. The policy bearing the endorsement of
Appointment of Appointee duly executed must be sent to the Branch Office of the
Corporation for registration.
296
Form No 3293 (a)
To
The Senior / Branch Manager,

________________________________
Re : Proposal on the life of my son / daughter.
With reference to the proposal for Rs. ………………….. on the life of my 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 the life assured, I shall
utilize the moneys thereby received for the benefit of the minor or his/her estate.
___________________________
__________________________
Signature of witness Signature of the proposer
Name :
Occupation :
Address :
297
Form No.3301 (R)
Ref : NB/Med.
Date : ………………….
Dear Doctor,
We have the pleasure in informing you that you have been selected for the panel
of authorized Medical Examiners for the Life Insurance Corporation of India at your
address given below to examine applicants proposing for insurance upto the maximum
amount specified.
Your Code Number is also given at the end. This Code Number must be quoted
in each and every Medical Report you will submit as well as in all your correspondence
with the Corporation its Zonal, Divisional or Branch Offices.
A copy of the Medical Examiner’s Diary is sent to you herewith. You are
requested to study the instructions contained therein very carefully and comply with them
in conducting the medical examinations and in submitting report thereon to the
Corporation. We would specially request you to satisfy yourself about the identity of the
proponents who will be presented for medical examination before you.
We would take this opportunity to point out that in selecting you as a Medical
Examiner the Corporation has put its full trust in you. Your report will form the basis on
which the lives you examine will be assessed for Life Insurance, and the Corporation
expects that you will prove yourself worthy of its trust.
Your Medical Report form should be filled in as soon after the examination as
possible and forwarded immediately to the address of the controlling Office given below.
You are also requested to enclose with your report, the agent’s confidential report which
the agent will hand over to you.
You should keep for your own record a copy of the measurement and other
Particulars of your examination in each case, for which purpose the diary referred to
above is sent to you.
The terms and conditions on which you are offered appointment as the authorized
Medical Examiner for the LIC and the scale of fees which will be payable to you are
printed on the reverse and these must be strictly adhered to by you. If you accept the said
298
terms and conditions and are agreeable to work as Medical Examiner strictly on these
terms and conditions, you may start working as such immediately but in case you are not
agreeable you may inform the Divisional / Branch Office of the Corporation at the
address given above by return of post, failing which it will be presumed that you accept
the appointment.
Yours faithfully,
Manager (NB)
IMPORTANT
This appointment gets cancelled automatically the moment you are transferred out of the
place of authorization on vide (i) below and you should not examine cases at the new
place without our sanction.
Encls : Medical Diary, and Medical Report pad.
1. You are selected to examine applicants for Life assurance at :
2. Your maximum authorized Limit :
3. Your Code Number :
4. The controlling Office to which you should send your medical reports.
TERMS & CONDITIONS
1. The Medical Examiner will examine the proponents for Life Assurance only at
the place mentioned in this letter. If any examination is conducted at a place other
than that mentioned in this letter without the specific authority in writing from the
controlling Branch Office, it will be treated as a breach of conditions of
appointment which may lead to termination of the appointment.
2. The Medical Examiner must be readily available for at least 3 hours daily at the
address mentioned in this letter.
3. The Medical Examiner will be retired on the attainment of age 65. On retirement
all unused stationery belonging to the Corporation should be returned to the
Controlling Office of the Corporation.
4. The Medical Examiner will receive fees at following scale.
299
Sum Assured Fees
FULL MEDICAL REPORT FOR SUM PROPOSED
i) Upto and including Rs.3 lacs Rs. 60/-
ii) Rs.3,00,001 to 15 lacs Rs.70/-
iii) Rs.15,00,001 to Rs.24,99,999/- Rs.95/-
iv) Rs.25 lacs and above Rs.120/-
5. The Medical Examiner should under no circumstances examine a person in case :
(h) he is related to the Proposed life to be assured, Agent or Development Officer
the proposer, the Life to be assured, Agent or Development Officer is his

employer, employee or immediate colleague in service.
6. The Medical Examiner must possess and maintain in a good state of proper
weighing machine recording to kilograms a measuring scale and a tape marked in
centimeters and fractions there of and Sphygmomanometer. The medical
Examiner must permit persons duly authorised by the Corporation, to have access
to these instruments for inspection and checking.
7. The Medical Examiner must himself forward the medical report to the controlling
office of the Corporation in a closed envelope, soon after the completion of the
medical examination. The medical report may be handed over to the introducing
agent or Development Officer of the Corporation in sealed envelope.
8. The Medical Examiner must scrupulously observe all the instructions and
directions contained in the Medical examiner’s Diary as well as such other
instructions and directions as the Corporation may issue from time to time.
9. The Medical Examiner shall not exceed the ceiling of No. of cases per quarter as
mentioned here under :
April to July to October to Jan to Total

per
June September December March Annum
50 75 150 200 475
10. Any breach of these terms and conditions of appointment or of the instructions
contained in the Medical Examiner’s Dairy or such other instructions or directions
as may be given by the Corporation from time to time will render the Medical
Examiner liable for termination of his appointment.
300
11. The Corporation reserves to itself the right to terminate the appointment without
assigning any reasons therefor.
12. Medical fees will not be paid by the Corporation for proposals under plan 43, 52,
58 & 94. For these plans the Medical Examiner should insist on payment of
medical fees from the proposer.
13. And also for revival cases and plans with term rider benefit and premium Waiver
benefit the medical fees are to be collected from the policy holder / proponent.
301
Branch ……………………………………
Dear Sir,
Re : Panel of Medical Examiners of the

Your name has been suggested for being considered for appointment as a Medical
Examiner for the Corporation. A form calling for certain relevant information is,
therefore, given on the back hereof. If you are interested and willing to work as a
Medical Examiner for the Corporation, kindly fill up the form and return it to the
address given above.
Yours faithfully,
p. Sr . / Branch Manager
302
FORM NO. 3302
MEDICAL EXAMINER’S APPLICATION FORM
1. Name in full (In Block letters)
2. Address in full (in Block Letters)

i) Residence : (i)
ii) Dispensary /Consulting Rooms (ii)

:
(iii)
iii) Telephone Number :
3. (i) Normal hours of attendance at the (i)
dispensary or consulting rooms :
(ii) Availability for Medical (ii)
Examination
(No. of hours per day and the
timings
thereof)
4. (i) Date of Birth : (i)
(ii) Completed Age : (ii) (ii) Sex
5. Medical Qualifications : Name of University Year of
or Institution Confirment
Degrees or
Diplomas
(i)
(ii)
(iii)
6. Are you a member of any Medical
Society?
If so, state which society.
7. Are you a Registered Medical
Practitioner?
If so, state your registered number.
8. Are you in practice at present? If so,
since
which year.
9. If you are specialized in any branch of

medicine give full details regarding :
303
i) The nature of your work. (i)
ii) The degrees and diplomas held (ii)

in specialized branch.
iii) Whether attached to any (iii)

hospital or institution and if so
position held.
(iv)
iv) Whether practice is restricted to
your specialization or you are
doing general medical practice
also.
10. Do you hold any Government or

semi-government appointment? If so,
give full details and whether you are
allowed to do private practice (certificate
from your
employer to be attached.)
11. (a) Do you have a weighing machine (i) (a) Make :

in
metric system in perfect Date of purchase :
working
order? If so, state its make and (b)
date
of purchase.
(b) Date of Inspection by Inspector
of
weights and measures.
(ii) Do you have a Sphygmomanometer in (ii)
perfect working order? If so state its
make.
(iii) Have you arrangements in your (iii) (a)

consulting room for (a) E.C.G. (b) X-ray (b)
(c) Screening (c)
(d) Pathological examinations. (d)
If so, give details.
12. Have you specialized in radiology or
cardiology? If so, give full details.
304
13. Are your sight and hearing in perfectly
sound state?
14. Have you been our Medical Examiner previously? If so, give details.
Name of the Since Which year Limit Code No.

Division
15. Have you at any time ceased examining (either by resignation or termination) cases
for any other Division? If so, give details below :
Name of the Divisional Year when stopped Reasons if any

Office Examination
16. Have you any relatives working for the

Corporation in the capacity of an Agent/
Development Officer or otherwise? If so,
give details.
Place :
…………………………….
Date :
(Signature)
305
3318
306
3441 A & B
307
Form No 3868-A
Place…………………………… Date……………………………….
The Sr. Branch Manager,

Life Insurance Corporation of India,
Divisional Office.
Dear Sir,
Re :- Policy No…………………………………..
I hereby give you * notice that I have assigned the above policy to
myself…………………. And my wife……………………………………………………
of……………………………………………………………………………………………
………………………………………………………………………………………………
(Addresses of the assignees)
on…………………………
Please acknowledge receipt of this notice and forward the enclosed policy / Deed of
assignment to……………………………………………………………………………..
…………………………………………………………………………………………….
after registering the assignment thereon in your books. A copy of the assignment is also
enclosed for your record.
Yours faithfully,
……………………………………
(Signature of Assignor, viz, Assured)
*Notice should be given by the assignor or his /her /their duly authorized agents.
308
Form No 3868-B
Place………………………………………Date………………………………………..
The Sr. Branch Manager
Dear Sir,
Policy No…………………………………………
We hereby give you * notice that we have assigned the above Policy to………………
………………………………………………………………………………………………
Name and Addresses of the Assignees
………………………………………………………………………………………………
………………………………………………………………………………………………
on…………………..
Please acknowledge receipt of this notice and forward the enclosed Policy / Deed of
Assignment to…………………………………………………………………………….
After registering the assignment thereon in your books. A copy of the assignment is also
enclosed for your records.
Yours faithfully,
1…………………………………….
2…………………………………….
(Signatures of Assignors, viz., Assured & his wife.)
*Notice should be given by this assignor or his/ her/ their duly authorized agents.
309
Form No. NB/44
LIC OF INDIA, __________ Divisional Office

__________________Branch Office
Branch Manager's Recommendation for appointment of Medical Examiners.
1.Name of the doctor :
2.Qualification (with year of passing) :
3.Age and Date of Birth :
4.Station where the appointment of the doctor

is desired and the approx. population :
5.Are there any appointed medical examiners

at the station ? If so, give details. : Number of
Limit: Male Drs. Lady Drs.(Where applicable)
1 Lakh
2 Lakhs
3 Lakhs
4 Lakhs
5 Lakhs and above
6.Are there any other doctor senior to the
applicant available at the station who have
not been appointed by us so far? If so,please
give details. :
7.If the reply to Qn. 6 is in the negative,

please state the nearest place where such
senior unappointed doctors are available. :
8. a)The No.of Field Officers/and/or Agents at

the station :
b)No.of medical cases received during the

previous financial year at the station. :
9.In case there are senior unappointed doctors

at the place, state special reasons for
recommending this doctor. :
10.a)Is the Medical examiner related to any

Dev.Officer,Agent or any Official of LIC? :
310
b) If so how ? :
11.Are you satisfied that this doctor is equi-

pped with all racilities to conduct medical
examination at the above centre and if appo-
inted will give reliable medical reports? :
12.Name,if any,of the person who has recommended

the appointment of the medical examinar. :
__________________
Date : Sr./ Branch Manager
--------------------------------------------------------------------------------
Note: For Divl. Office Use
1.Standing of the doctor in Profession :
2.Limit upto which he could be appointed

as per manual. :
3.Number of authorised doctors at the centre :
4.No. of Medl. examiners allowed :
5.Spl.reasons if any for appointing the doctor :
Decision of the Divl.Manager.
311
Cardiologist,radiologist application form
312
REVIVAL RATING SHEET
Policy No. Unit / D.O.

Corresponding Proposal No Received on
Name Original Plan
Previous occupation Corporation’s Plan
Present occupation Original Sum Assured
Risk Date How accepted
Date of lapse Outstanding Terms (i) As at the date of
lapse Rs
(ii) As at present:
Age at entry DOB Sum at risk :
(i) As at the date of lapse Rs.
(ii) As at present Rs.
Present age
Name of M.E. Dt of He Wei Abd Chest B.P. Pulse Age

Exam ight ght.
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
Evidence of health received. Special reports received.
FACTORS Particulars Mortality ratings

1. FAMILY HISTORY:
(i) Longevity
(ii) Heredity.
2. BUILD: (St. weight………….)
Percentage weight
Chest Exp. (for + / - wts)
Abdomen (for + / - wts)
Endowment Terms(for +weights)
3.Blood Pressure { FMR
{ECG
{PHY REPORT
AVERAGE BP…………………….
4. PULSE RATE
5. OTHER ADVERSE FEATURES
Total Mortality Rating -----------------------

Corresponding Extra -----------------------
Add Occupation & Total extra Rs ---------------------
313
NB Re-Check Report
Division___________________ Branch Office _______________
Date ___________
Proposal No./Policy No._______________
On the life of ______________________________________________
Height(without shoes) ………………… (in cms.)____________
Weight(with thin clothes)………………… (in kgs) ___________
Chest(Over Nipples Stripped)……………… (in cms.)____________
On complete Expiration ……………………. ______________
On Full Inspiration ………………………….. _______________
Abdomen(Over Naval) Stripped……………… _______________
Marks of Identification…………………………. _____________
_________________________ _____________________________________
Signature of Proposer/Life Assured Signature of Medical Examiner with seal/Branch
Manager
314
Form No. 1
(Corresponding to Clause No 23)

To be used in the following case:

1. Policy to be effected under the Married Women’s Property Act, 1874, for the benefit of ONE Beneficiary
(wife , son or daughter)
2. Appointment of Two or more trustees jointly or survivor.
1. What is the object this Assurance? Is This policy is proposed to be effected for the sole and
it to effect a policy under the Married absolute benefit of my
Women’s Property Act, 1874 for the _____________________________________________
Benefit of your wife,son or daughter? (relationship, full name and age of the beneficiary)
If so, give particulars
________________________________ pursuant to the provisions of Section 6 of the
2. If the object, is to effect a policy under Married Women’s Property Act,1874, and I declare
The Married Women’s Property Act, that the Policy shall have the same incidents as are
1874 whom do you wish to appoint as prescribed in the Section 6 of the said Act, as if that
Special Trustee ? Section had been incorporated in the Policy and
________________________________ neither I nor my estate shall have any interest in
the same.
Witness:
I request the Policy to be issued under the provisions
Of the Married Women’s Property Act, 1874
Signature……………………………. For the absolute benefit of the beneficiary aforesaid
Full Name…………………………… in the manner aforesaid and I hereby appoint …….
Occupation…………………………. And…………………………………………………….
Address……………………………... (full names of Special Trustees)
Witness: Jointly or survivors or survivor of them to be the
Special trustees to receive the Policy monies and
Signature……………………………. Hold the same in trust for the said beneficiary
Full Name…………………………… under the provisions of the said Act and in case
Occupation…………………………. Any one of the said Trustees dies or declines to act
Address……………………………... or becomes incapable to act or is disqualified from
Acting under the law or cannot act as trustee for
Witness: any reason whatsoever then I shall have power by
A deed to fill the vacancy by appointing a new
315
Signature……………………………. Special trustee or trustees in place of such trustee or Full
Name…………………………… trustees to receive the policy moneys and to hold
Occupation…………………………. The same in trust for the said beneficiary under the
Address……………………………... provisions of the said Act.
Provided that I shall have the right to revoke the

Appointment of any of the aforesaid Special
Trustee or both and appoint others in their stead
*And I hereby authorize the said Special Trustees

to obtain any loan or loans on the security of the
Policy from the Life Insurance Corporation of
India for the benefit of the above named
Beneficiary provided he /she is a major and
Competent to contract.
The consent of the said trustees to act is endorsed

below:
Dated at…………………on……………….day of
………………..20
……………………………………………………..
I agree to act as Special Trustee as aforesaid

……………………………………………………..
Signature of Trustee and his / her address
……………………………………………………
*Strike out the whole clause if not desired or portion

of the restriction reading as “Provided the
beneficiaries are major and competent to contract and
all are of sound mind, “ if the power to raise loan
is desired to be given to the Trustees even if the
beneficiary / ies are minors.
316
Form No. 1-A
(Corresponding to Clause No 23-A)


2. Appointment of One person as a Special Trustee.
Benefit of your wife, and / or sons and/
or daughters? (relationship, full name and age of the beneficiary)
2. If the object, is to effect a policy under Married Women’s Property Act,1874, and I declare
the same.
Witness:
Occupation…………………………. And…………………………………………………….
Address……………………………... (full name of Special Trustee)
Witness: as a Special trustee to receive the Policy monies and
Signature……………………………. hold the same in trust for the said beneficiary
Full Name…………………………… under the provisions of the said Act and in case
Occupation…………………………. the said special Trustee dies or declines to act
Address……………………………... or becomes incapable to act as trustee under the Law
Witness: or cannot act any reason whatsoever then I shall have
Power by a Deed to appoint a new Special Trustee
Signature……………………………. or trustees to receive the policy moneys and to hold
317
Occupation…………………………. for the said beneficiary under the provisions of the
Address……………………………... said Act.

Trustee and appoint another in his / her stead
*And I hereby authorize the said Special Trustee

policy from the Life Insurance Corporation of
beneficiary provided he /she is a major and
competent to contract.
The consent of the said trustee to act is endorsed

below:
………………..20
……………………………………………………..
……………………………………………………..

318
Form No. 2


2. Appointment of One Trustee and Alternate Trustee.
Benefit of your wife, son or daughter ?
(relationship, full name and age of the beneficiary)
2. If the object, is to effect a policy under Married Women’s Property Act, 1874, and I declare
the same.
Witness:
Occupation…………………………. And…………………………………………………….
Address……………………………... (full name of the Principal Special Trustee)
Witness: or failing him / her or if he / she dies or declines to act
Signature……………………………. or becomes incapable to act or is disqualified to act as
Full Name…………………………… Special Trustee under the law or cannot act for any
Occupation…………………………. Reason whatsoever.
Address……………………………... _____________________________________________
Witness: (full name of Alternate Special Trustee)
Signature……………………………. To be the Special Trustee to receive the policy moneys
319
Occupation…………………………. And to hold the same in front for the said beneficiary
Address……………………………... under the provisions of the said Act, and in case the
Said
--------------------------------------------------------------
(full name of the Principal Special Trustee)
or
___________________________________________
(full name of the Alternate Special Trustee)
dies or declines or becomes incapable to act or is
disqualified to act as Special Trustee under the law
or cannot act for any reason whatsoever, then
I shall have power by a Deed to appoint a new trustee
To receive the policy moneys and to hold the same
In trust for the said beneficiary under the
Provision of the said Act.

Trustees or both and appoint others in their stead
*And I hereby authorize the said Special Trustees

beneficiary provided he /she is a major and
The consent of the said trustee to act is endorsed

below:
………………..20
……………………………………………………..
……………………………………………………..
……………………………………………………..
320
321
Form No. 3


1. Policy to be effected under the Married Women’s Property Act, 1874, on the life of Non- Mohammadan
proposer for the benefit of Two or more beneficiaries (wife and / or sons and / or daughters) Jointly or
Survivors
2. Appointment of Two or More Trustees Jointly or Survivor.
Women’s Property Act, 1874 for the 1) _____________________*________________________
Benefit of your wife, son / or sons and / 2) _____________________*________________________
3)______________________*________________________
Or daughters? 4)_____________________ *________________________
If so, give particulars jointly or the survivors or survivor of them pursuant
________________________________ to the provisions of Section 6 of the Married Women’s
2. If the object, is to effect a policy under Property Act, 1874, and I declare that the Policy
The Married Women’s Property Act, shall have the same incidents as are prescribed in the
the same.
Witness:
Occupation…………………………. 5) ………………………*…………………………….
Address……………………………... 6)………………………...*…………………………….
7)………………………...*…………………………….
322
Witness: …………………………….. Jointly or survivors or survivor of them to be the
Signature……………………………. Special Trustees to receive the policy moneys and
Full Name…………………………… hold the same in trust for the said beneficiaries
Occupation…………………………. Under the provisions of the said Act and in case any
Address……………………………... of the said Special Trustees dies or declines to act or
Witness: declines to act or becomes incapable to act or is
Disqualified from acting under the law or cannot
Signature……………………………. Act as Special Trustee or cannot act for any reason
Occupation…………………………. Then I shall have power by a Deed to fill in the
Address……………………………... vacancy by appointing a new special trustee or
Trustees to receive the policy moneys and to hold
The same in trust for the said beneficiary under
The provisions of the said Act.

Trustees or of all of them and appoint others in their
Stead.
***And I hereby authorize the said Special Trustees
beneficiaries provided they are all major and

below:
………………..20
……………………………………………………..
……………………………………………………..
Signature of Special Trustee and his / her address
……………………………………………………..
* Give relationship, full name and ages of beneficiaries
** Give full name of trustees
323
***Strike out the whole clause if not desired or portion
all are of one mind, “ if the power to raise loan
324
Form No. 4


1. Policy to be effected under the Married Women’s Property Act, 1874, on the life of Non- Mohammadan
proposer for the benefit of Two or more beneficiaries (wife and / or sons and / or daughters) Jointly or
Survivors
2. Appointment of One Trustee Jointly or Survivor.
Benefit of your wife, son / or sons
and /or daughters? 2) _____________________ *________________________
3)______________________*________________________
4)_____________________ *_____________________
If so, give particulars jointly or the survivors or survivor of them pursuant
the same.
Witness:
of the Married Women’s Property Act, 1874
Signature……………………………. for the absolute benefit of the beneficiaries aforesaid
Occupation…………………………. 5) ………………………*…………………………….
Address……………………………... (full name of the Principal Special Trustee)
or failing him / her or if he / she dies, declines or
becomes incapable to act, or cannot act for any
Witness: …………………………….. reason whatso
Signature……………………………. 6)…………………………………………………….
Full Name…………………………… (full name of the Alternate Special Trustee)
325
Occupation…………………………. Ever, to be Special Trustee to receive the Policy moneys
Address……………………………... and to hold the same in trust for the said
Witness: beneficiaries under the provisions of the said Act,
And in case the said
Signature……………………………. 7)………………………………………………….
Occupation…………………………. (full name of the Principal Special Trustee)
Address……………………………... or
8)………………………………………………….
(full name of the Alternate Special Trustee)
dies, declines or becomes incapable to act or is
disqualified to act as special trustee under the law
Address……………………………... or cannot act as for any reason whatsoever, then
I shall have power by a Deed to appoint a new
Special Trustee to receive the policy moneys and
To hold the same in trust for the said
Beneficiaries under the provisions of the said Act.
Trustees or of both and appoint others in their
Stead.
***And I hereby authorize the said Special Trustee
competent to contract and all of one mind.

below:
………………..20
……………………………………………………..
……………………………………………………..
……………………………………………………..
326
**Strike out the whole clause if not desired or portion
327
Form No. 5


1. Policy to be effected under the Married Women’s Property Act, 1874, for the benefit of Two or more
beneficiaries (wife and / or sons and / or daughters) in specified shares.
2. Appointment of Two or more trustees jointly or Survivor.
Benefit of your wife, son / or sons 2)_____________________*________________________
and /or daughters? If so,
give particulars 3) _____________________ *________________________
4)______________________*________________________
If so, give particulars in the shares of ______@______ pursuant

the same.
Witness:
Signature……………………………. for the absolute benefit of the beneficiaries aforesaid
Occupation…………………………. 5) ………………………*…………………………….
Address……………………………... 6)………………………..*……………………………
7)……………………….. *……………………………
Witness:
Signature………………………..
Full Name……………………….
Occupation ……………………..
Address Jointly or the survivors or survivor of them to be the
Special Trustees to receive the Policy moneys and to hold
328
the same in trust for the said beneficiaries under provisions
of the said Act and in case any of the said Special Trustees
dies or declines to act or becomes incapable to act or is
disqualified from acting under the law or cannot act as
Special Trustee for any reason
whatsoever then I shall have power by a Deed to fill in the
vacancy by appointing a new special trustee or trustees in
place of such trustee or trustees to receive the Policy
moneys and to hold the same in trust for the said
beneficiaries under the provisions of the said Act.
Stead.

competent to contract and all of one mind
below:
………………..20
……………………………………………………..
……………………………………………………..
Occupation…………………………. I agree to act as Special Trustee as aforesaid
……………………………………………………..

329
330
331
332
Form No. 6


1. Policy to be effected under the Married Women’s Property Act, 1874, on the life of Two or More
Beneficiaries (wife and / or sons and / or daughters) in specified shares.
2. Appointment of One Trustee and Alternate Trustee.
Women’s Property Act, 1874 for the 1) _____________________*__________________and
Benefit of your wife, and/ or sons
and /or daughters? If so, give particulars 2) _____________________ * __________________and
__________________________________ 3) ____________________ *__________________and
in the shares of_________-@_______pursuant to the

________________________________ provisions of Section 6 of the Married Women’s
1874 whom do you wish to appoint as said Section 6 of the said Act, as if that Section
Special Trustees ? had been incorporated in the Policy and neither
________________________________ I nor my estate shall have any interest in the same.
Witness:
Signature……………………………. for the absolute benefit of the beneficiary aforesaid
Occupation…………………………. ………………………………………………………….
Address……………………………... (Name of the Principal Special Trustee)
or failing him/ her or if he / she dies, declines or
is disqualified to act under the Law or cannot act for
any reason whatsoever.
………………………………………………………….
(Name of the Alternate Special Trustee)
to be the Special Trustee to receive the Policy moneys
333
Witness: …………………………….. and to hold the same in trust for the said beneficiaries
Signature…………………………… Under the provisions of the said Act, and in case the
Full Name…………………………… said
Occupation…………………………. ……………………………………………………….
(Name of the Principal Special Trustee)
Address…………………………….. or
………………………………………………………
(Name of the Alternate Special Trustee)
Witness:
Signature…………………………… dies or declines to act or becomes incapable to act
Full Name…………………………. or is disqualified to act as a Special Trustee
Occupation………………………… under the law or cannot act as for any
Address……………………………. reason whatsoever then I shall have power by a Deed
to appoint a new Special Trustee to receive the Policy
moneys and to hold the same in trust for the said
Beneficiaries under the provisions of the said Act.

appointment of any of the aforesaid Special
stead.

below:
………………..20
……………………………………………………..
……………………………………………………..
@ Give particulars of the shares of the beneficiaries
all of one mind, “ if the power to raise loan
334
Form No. 7


1. Policy to be effected under the Married Women’s Property Act, 1874, for the benefit of one Beneficiary
(wife, son or daughter)
2. Appointment of a Bank or a Trustee Company as Special Trustee.
Women’s Property Act, 1874 for the ______________________________________
Benefit of your wife, or son (relationship, full name and age of the beneficiary)
or daughter? If so, give particulars pursuant to the provisions of Section 6 of the Married
__________________________________ Women’s Property Act, 1874, and I declare that the
Policy shall have the same incidents as are prescribed in
the said Section 6 of the said Act, as if that Section had
had been incorporated in the Policy and neither I
nor my estate shall have any interest in the same.
________________________________
2. If the object, is to effect a policy under I request the Policy to be issued under the provisions
The Married Women’s Property Act, of the Married Women’s Property Act, 1874
1874 whom do you wish to appoint as for the absolute benefit of the beneficiary aforesaid
Special Trustees ? in the manner aforesaid and I hereby appoint …….
________________________________ ………………………………………………………….
(Full name of the Bank or the Trustee Co.)
Witness: (their successors and assigns to be the Special Trustee
Signature ………………………… to receive the Policy moneys and to hold the same in
Full Name………………………... Trust for the said beneficiary under the provisions of
Occupation………………………. the said Act and in case the said / Bank / Company
Address…………………………... declines or becomes incapable to act or is disqualified
to act as special trustee under the law or cannot act
Witness: for any reason whatsoever then I shall have power by
Signature………………………. a Deed to appoint a new Special Trustee to receive the
Full Name……………………… Policy moneys and to hold the same in trust for the said
Occupation…………………….. Beneficiary under the provisions of the said Act.
335
Witness: …………………………….. Provided that I shall have the right to revoke the
Full Name…………………………... appointment of any of the aforesaid Special
Occupation………………………… Trustees and appoint others in their
Address……………………………. stead.

beneficiary provided he /she is major and
below:
………………..20
……………………………………………………..
…………………………………………………
Signature of Special Trustee and their address

Note: Where State Bank of India or United Commercial
Bank have been appointed as Special Trustee, the words
“from the LIC of India” Appearing in the last para above
should be removed under the signature of the proposer.
336
Form No. 8


1. Policy to be effected under the Married Women’s Property Act, 1874, for the benefit of Two or More
Beneficiaries (wife and / or sons and / or daughters)
Women’s Property Act, 1874 for the (1)___________________*___________________
Benefit of your wife,and / or sons & (2)___________________*___________________
And / or daughters? If so, give & (3)___________________*___________________
Particulars. & (4)___________________*___________________
________________________________ jointly or survivors or survivor of them pursuant to
the provisions of Section 6 of the Married Women’s
________________________________ Property Act, 1874, and I declare that the policy
shall have the same incidents as are prescribed in
the said Section 6 of the said Act, as if that Section
2. If the object, is to effect a policy under had been incorporated in the policy and neither I nor
The Married Women’s Property Act, my estate shall have any interest in the same.
1874 whom do you wish to appoint as _____________________________________________
Special Trustees ? I request the Policy to be issued under the provisions of
________________________________ the Married Women’s Property Act, 1874, for the
absolute benefit of the beneficiaries aforesaid in
Witness: the manner aforesaid and I hereby appoint.
Signature ………………………… ___________________________________________
Full Name………………………... (full name of the Bank / Trustee Co)
Occupation………………………. their sucessors and assigns to be the Special Trustee
Address…………………………... to receive the Policy moneys and to hold the same
In trust for the said beneficiaries under the provisions
Witness: of the said Act and in case the said Bank / Company
Signature………………………. Declines or becomes incapable to act or is disqualified
Full Name……………………… to act as Special Trustee under the law or cannot act
Occupation…………………….. for any reason whatsoever, then I shall have power by
Deed to appoint a new Special Trustee or Trustees
337
To receive the policy moneys and to hold the same in
Trust for the said beneficiaries under the provisions
Witness: …………………………….. of the said Act.


beneficiary provided they are all major and
below:
………………..20
……………………………………………………..
…………………………………………………

* Give relationship, full names and ages of beneficiaries

338
Form No. 9


1. Policy to be effected under the Married Women’s Property Act, 1874, for the benefit of Two or
More Beneficiaries (wife and / or sons and / or daughters) in specified shares.
Women’s Property Act, 1874 for the (1)___________________ *______________and
Benefit of your wife, and / or sons &(2)___________________*______________and
And / or daughters? If so, give &(3)___________________*______________and
Particulars. &(4)__________________ *______________and
________________________________ in the shares of ____________@______________
pursuant to the provisions of Section 6 of the Married
Women’s Property Act, 1874, and I declare that the
policy shall have the same incidents as are prescribed in
the said Section 6 of the said Act, as if that Section
2. If the object, is to effect a policy under had been incorporated in the policy and neither I nor
The Married Women’s Property Act, my estate shall have any interest in the same.
1874 whom do you wish to appoint as _____________________________________________
Special Trustees ? I request the Policy to be issued under the provisions of
________________________________ the Married Women’s Property Act, 1874, for the
absolute benefit of the beneficiaries aforesaid in
Witness: the manner aforesaid and I hereby appoint.
Signature ………………………… ___________________________________________
Full Name………………………... (full name of the Bank / Trustee Co)
Occupation………………………. their sucessors and assigns to be the Special Trustee
Address…………………………... to receive the Policy moneys and to hold the same
in trust for the said beneficiaries under the provisions
Witness: of the said Act and in case the said Bank / Company
Signature………………………. declines or becomes incapable to act or is disqualified
Full Name……………………… to act as Special Trustee under the law or cannot act
Occupation…………………….. for any reason whatsoever, then I shall have power by
deed to appoint a new Special Trustee or Trustees
To receive the policy moneys and to hold the same in
Trust for the said beneficiaries under the provisions
of the said Act.
339
Witness: …………………………….. Provided that I shall have the right to revoke the
**And I hereby authorize the said Special Trustees

beneficiary provided they are all major and
below:
………………..20
……………………………………………………..
We agree to act as Special Trustee as aforesaid
…………………………………………………

* Give relationship, full names and ages of beneficiaries
@ Give particulars of the shares of the beneficiaries.
340
341
342

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INDEX

List of Divisional Office (New Business) Forms (Except Policy Forms)

Proposal / Policy Clauses

Sr Clause Description Form No

LETTERS TO PROPOSERS/POLICY HOLDERS

Sr Clause Description Form No When Applicable Insertions

4 10a Special Minority Clause 3130 A Applicable in

13 23 A Special Clause for policies 3143 (A) When Addendum (a)Beneficiary’s

13 24 Special Clause for policies 3144 When Addendum (a)Beneficiary’s

14 25 Special Clause for policies 3145 When addendum (a)Beneficiary’s

16 27 Special Clause for policies 3147 When addendum (a)Beneficiary’s

18 31 Applicable to policies relating 3151 When the Exact percentage

31 65 Special Aviation Clause 3214 Applicable in the

Proposal Clause No.1 Form No. 3121

LIFE INSURANCE CORPORATION OF INDIA

p. Sr. Branch Manager

Proposal Clause No.2 Form No.3122

LIFE INSURANCE CORPORATION OF INDIA

Notwithstanding anything within-mentioned to the contrary, it is hereby declared and

p. Sr. Branch Manager

Proposal Clause No 4(b) Form No.3124 (b)

LIFE INSURANCE CORPORATION OF INDIA

Sr. Branch Manager

Proposal Clause No. 10(a) Form No. 3130(a)

LIFE INSURANCE CORPORATION OF INDIA

LIFE INSURANCE CORPORATION OF INDIA

the amount payable under this Policy shall be limited to either -

p .Sr. Branch Manager

Proposal Clause No 13 Form No 3133

Life Insurance Corporation of India

Special Aviation Clause (Ground Branches Personnel)

Notwithstanding anything within-mentioned to the contrary, it is hereby declared and

p. Sr. Branch Manager

Proposal Clause No.14 Form No. 3134

LIFE INSURANCE CORPORATION OF INDIA

Re: Occupation Endorsement Clause

p. Sr. Branch Manager.

Proposal clause no 20 Form No 3140

LIFE INSURANCE CORPORATION OF INDIA

In consideration of the payment of an additional installment premium of Rs

Clause No.20A Form.No. 3140 A

MONEY BACK CHILDREN’S ASSURANCE – WAIVER OF PREMIUM CLAUSE 20A

Proposal Clause 20 (B) Clause No 3140 (B)

LIFE INSURANCE CORPORATION OF INDIA

1) Annual premium policy:

In consideration of the payment of an additional instalment premium of

a) A sum of Rs…………….. will be paid as Family Benefit in case of death of the

LIFE INSURANCE CORPORATION OF INDIA

Signature of the policyholder Signature of the witness

LIFE INSURANCE CORPORATION OF INDIA

1. The instalment premium as mentioned on the schedule of the policy to be issued

Dated at---------------on the------------day of----- (Month)----------(Year)

SIGNATURE OF WITNESS: SIGNATURE OF THE POLICYHOLDER

Clause No. 23 Form No. 3143

LIFE INSURANCE CORPORATION OF INDIA

For THE LIFE INSURANCE CORPORATION OF INDIA

Clause No. 23(A) Form No. 3143(A)

LIFE INSURANCE CORPORATION OF INDIA

for the benefit of the Proposer's__________________________________________________

aged _____________years and ___________________________________________________

For THE LIFE INSURANCE CORPORATION OF INDIA

Clause No.24 Form No. 3144

aged _years and _______________________________________

aged _years and _______________________________________

(1) * aged _years,

(1) * aged _years,

(1) * aged _years,

(1) * aged _years,

in the shares of __________________________respectively, and _

Dated at ___ this day of _20________

Dated at ________this day of _20

Dated at___________this _day of _____________20