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I MEDICAL PR'OPOSAL I

Proposal form No. Proposal Serial No.

/'(/v..:/1j/) 341037 .IF/. .:;./I}/)
02 031

Address of Zonal Office: ZONAL OFFICE:

ESTABLISHED UNDER ARTICLE 11 (1) OF STAE LIFE BUILDING
THe LIFe INSURANCE NATINOALIZATIONS ORDeR 2·Llaqat Road, Falsalabad.
1972 (P.O. 10 OF 1972) PH: 111·555·888
IMPORTANT
Plo•• o nota that you Iml roqulrud to glvD corroct Rl1dtruthful
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IIrlawor of thll qllOGtlol1~ glvlln billow. Any concealment tj'i•....
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of facts or untrue stnt.monta shllil render tho contract voidable
and no bonotlt undGrthe contrnct shllil be paid. -r•.••",,J.:...J
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-1. Lifo Proposod'lI full nome (IN CAPITAL LETTERS)

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2. N. I. C. NO.:
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3. Father's I Husband's Name of life proposed
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4. Name of Proposer if other than life proposed (if yes, also fill in separate supplementary proposal form)
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5. Name of the child lift) proposed (if Child Protection Policy)

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PARTICULARS OF LIFE PROPOSED (J,/L/;/)

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6. Birth Plac~
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10. What age proof will you give? ~·Lv:.!r..!-·;lfJ.l,~.::.-y.L<;,,/( . 11. Nalionality ~' 12. Religion ..,...'~ /--"'J
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13. Address for correspondo~. ';:';? L

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14. Permanent residential address

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15. E-mail address ~'(J:'JI 16. Phone No. /:
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18. Nature of work I occupation (with full details)
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19. Eillployer's name & address
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20. If businessman. state nature of business
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21. Name of business & address

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22. If holding agricultural land, state size, location and;-:w:-:;l~le-:;:t1::-1e:-::r-T----------.....:....---------I
Neheri or Barani
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23. What is your average monthly income from all sources?

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24. If Defence or Ex-Defence Personnel, commercial airline flight crew or
Plant Protection Pilot, State latest medical category.
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25. Have you ever been discharged on medical ground from service/
employment? If so give details.
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26. Are }'OU prcsently cng;lgc(j' or intend to 1?I1~PgCin haznrdous
occupation or pastnne? If so. Dive dc't ..lils.
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27. Give details of each and every other proposal/ policy on your life including those declined / pending / postponed /
cancelled /Iapsed /not-taken-up / paid up / surrendered / accepted with extra premium, restrictions or modifications.
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Policy / I Name of SlUIl Assured -::);~ Accepted/Rejected Year of Issue I Sfatus ~
Proposal No. Company / Zone If accepted, state
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Accident

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I terms of acceptance
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Inforce / Lapsed / Paid-up /
Surre~de~ed ~ others
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28, Plan 29. Table 30. Term :: ,31. Sum Assured: Rs.
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32. Tick (v") Against dnsirod suppicmentarv (:;) and cross out (x) others.
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contract
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Acci~;!H1tal
O~".th;;:indelllnity' Benefit(,l>,IB)"'---------r;-0 AcCide;,laID:ath S.0nefit(ADS) D
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Iertn Ins ur.uu-c t,ickr (lIR: __. __,_ ... _ III1WS IlH .
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Guaranteedinsurability (GI)
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HospitalS Surgical Benefit(H&S)

Refund of ~rornlum ~Id~r (RPR)-,----

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33. Tick (",) a desired mode of premium p~ment and cross (X) others QLY MLY
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I Banker's order/Ordinary
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34. State particular of first premium deposit: (a) Receipt No. (b) Dated

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For Rs. _ t.'LI/. Dcash ;:;, 0 Cheque ~ ODD ..0IJHv.J
35, Name & Address of usual medical attendent of family doctor .:;(t(~["-jl.tt.:(]/ ,J!; (k(~
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36, Name of nomlnee(s) under Section 72 of Insurance Ordinance 2000)

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(b) N,I.Q Ne. In tlB§i! of adult er

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(e) Ago) Go, (d) RelatiOi'lshlp with you ~Jj;\pL ~ r (J£!'" ~
minoa Is a minor an AppOi;1te~ u~d&r Section 72 of lnsurance Ordlnanco 2000 must bo d08lgnatod.
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(e) Appointee's Name (f) Appoi es's Relationship with nominee
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