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LIFE INSURANCE CORPORATION OF INDIA
(Established by the Life Insurance Corporation
Act, 1956)

PROPOSAL FOR INSURANCE ON THE LIFE OF ANOTHER PERSON
(To be used for Insurance on the Lives both of Minors & Adult)
DIVISIONAL OFFICE:
(All answers to be filled in legibly; Answers must be
given in words, Stroke of the pen or dots or dashes
will not be accepted as replies)

	Form No.340(Rev.93)
Proposal No.	Branch

Agent Code Number	DO Code

Inward Number	Date

FOLLOWING QUESTIONS TO BE ANSWERED BY THE PROPOSER

Full Name (Surname First) and Address to which communications are to be sent	Object of Insurance

	Age	Sex	Nationality
Pin Code
Telephone No.

Permanent Residential address,	Relationship with Life Assured	Occupation

2. Full name of the Life Assured	Sex	Nationality

	Present Occupation and nature of duties	Length of service

3. Short name of Life Assured	Full name (Surname first) of the father of the Life Assured

4.

Date of birth of the Life Assured	Age (nearer birthday)	Nature of Age Proof	Place of birth

Following Questions to be Answered by the Proposer if the Life to be Assured is Minor
5. If the proposal is under Children's Deferred Assurance Plan/Children's Anticipated Plan
(a) State whether you wish to secure Premium Waiver Benefit in case of your death before the commencement of risk.
(b) Do you agree to the condition that the policy if issued on the basis of this proposal will automatically vest in the life to be assured on the deferred date?
6 If the proposal is under any other plan, do you agree to the condition that the policy if issued on the basis of this proposal will automatically vest in the life to be assured on his/her attaining the age of majority?

7
Plan & Term	Sum Proposed (Rs.)	Is Accident Benefit required	If Policy is to be dated back, indicate date	Amount deposited Rs.	BOC No.
(Years)
Mode		Paying Authority Code	Dept. No.	Badge or S.R.No.

FOR OFFICE USE ONLY

Rid	Policy Number	Risk Date	Plan	Term	PPT	Sum Assured

Mode	Inst. Premium	No. of Dues	Next Due	DAB Prem	Extra Prem	Age	Age Proof Code	Sex Code	M/NMG/NMS

RUFS

Acceptance Code

Imp Indn

EMR Code

Reins

Income Code

Occ Code

Bill Type

Title

Rein.

Dist.

Taluk

Vilg.

Final Underwriting Decision with Underwriter's Full Signature

Date of Completion

Date of last Payment

Date of Maturity


Cash Option	Deferred Date	Vesting Date

8 Is your life now being proposed for another assurance or an application for revival of a policy on your life under consideration in any office of the corporation? If yes, give details
9 Please give details of your previous insurance:

Name of the divisional office of the corporation or of the Insurer	Policy Number	Sum Assured	Plan of Assurance	Year of issue of Policy MM/YY	Whether accepted as proposed at ordinary rates	with Accident Benifit	Medical or non -Medical	Whether in force for the full sum assured	If not give due date of last premium paid and mode of payment MM/YY

*N.B.: Corporation does not entertain any fresh proposal for insurance where any previous Policy has lapsed or has been converted into a paid up policy within the last 3 years.
10 Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation ever been:
(a) Withdrawn or dropped?		(c) Accepted with an extra premium or lien?
(b) Deferred or declined?		(d) Accepted on terms otherwise than those proposed? If yes, state
If so, give details

11 Have you any prospect or intention of engaging in aviation or of entering naval or military service or taking up any other hazardous occupation or pursuit? If so give details

12(a) What has been your usual state of health?
(b) Have you any bodily defects or deformity? If so give details
(c) Have you had i) Small Pox or ii) Successful vaccination	i) ii)
(d) (i) Are you suffering from Pyorrhoea?
(ii) State number of missing teeth, if any?
(iii) For how many missing teeth a denture is worn?
13 Have you ever suffered from or are you suffering from:	If 'YES' describe fully each ailment giving its nature, the number of attacks, dates, duration, severity, treatment taken, result and names and addresses of doctors consulted.
(a) Persistent cough, asthma, bronchitis, pneumonia, pleurisy, spitting of blood, tuberculosis or any disease of lungs?
(b) High or low blood pressure, rheumatic fever pain in chest, breathlessness, palpitation, infarction or any disease of the heart or arteries?
(c) Peptic ulcer, colitis, jaundice, anaomia, piles, dysentery or any disease of the stomach, liver, spleen, gall bladder or pancreas?
(d) Any disease of kidney, prostate, or urinary system?
alysis, insanity, epilepsy, fits of any kind or nervous breakdown or any other disease of the brain or the nervous system?
(f) Hemia, hydrocele, varicocele, fistula, varicose veins, skin eruption filariasis, goitre, gonorrohea, syphilis or any other venereal disease?
(g) Cancer, leprosy, rheumatism, gout, enlarged glands or tumours?
(h) Any disease of the ear, nose, throat or eyes including defective sight or hearing and discharge from the ears?
14 Have you been suspected of diabetes or are you suffering from diabetes or have you ever passed sugar, albumin, pus or blood in urine?
15 Have you consulted a medical practitioner within the last five years of any ailments requiring treatment for more than a week?
16 Have you remained absent from place of your work on grounds of health during the last 5 years?
17(a) Did you ever have any operation, accident or injury?
(b) Have you ever had an Electrocardiogram, X-Ray or Screening, Blood, Urine or Stool examination?
(c) Have you ever been in any hospital, asylum or sanatorium, for check-up, observation, treatment or any operation?
18 Do you use or have you ever used alcoholic drinks, narcotics or any other drugs? If so, what? Also state quantity consumed per day?
19 Has any of your relations, living or dead, suffered from any hereditary or infectious disease like diabetes, insanity, epilepsy, gout, asthma, tuberculosis, cancer, leprosy etc?
20 If the proposal is to be considered without medical report (i.e., Non-Medical basis) state:	(a) Your height (without shoes)	cms
	(b) Your exact weight (with thin clothes)	kgs

21 Give name and address of your usual medical attendant	Full Name
	Address

22 For the purpose of reference, give name and permanent address of a friend?	Full Name
	Occupation
	Full Address

23 Family History	LIVING		DEAD
	Age	State of Health	Age at Death	Cause of Death
Father
Mother
Brothers: Living No. Dead No.
Sisters: Living No. Dead No.
Wife / Husband
Children: Living No. Dead No.

24FOR MINOR LIVES ONLY: Give below the particulars of all the assurances in full force on the lives of your parents brothers and sisters

Relationship	Policy Number	Sum Assured

Additional questions to be answered by Female Life to be Assured (Questions 25 to 27)

(a) Your Educational Qualifications

b) Your average monthly income

(d) Whether you pay income tax

26 If you are married, please state (a) Husband's Full Name

(b) His occupation

Rs.

(d) Details of Husband’s insurance

Office of the Corporation	Policy No.	Sum Assured	Plan & Term	Present condition of the policy

27 For Female Cases only

(a) Do you observe Purdah?

(f) Have you had any abortion or miscarriage?

(b) Have the menstrual periods always been regular and painless?

(g) Did you have any complication related to pregnancy?

(h) Have you any weakness or injury resulting from Child-bearing or miscarriage?

(d) Are you pregnant now?

(i) Have you suffered or are you suffering any disease of breast, overies or uterus?

(e) State the date of last delivery?

DECLARATION BY THE LIFE TO BE ASSURED

I, (Name of the Life to be assured) whose life is herein before proposed to be assured do hereby declare that the statements and answers under headings 8 to 27 of the proposal form 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.

Notwithstanding the provisions of any law, usage custom or convention for the time being in force prohibiting any doctor, hospital, and/or employer from divulging any knowledge or information about me concerning my health or employment, on the grounds of secrecy, I, my heirs, executions administrators and assigns or any other person or persons having interest of any kind whatsoever in the Policy contract issued to me hereby agree hat such authority having such knowledge or information shall at any time be at liberty to divulge any such knowledge or information to the Corporation.

Dated at On the day of , 2000

Signature of witness

(Signature of thumb impression of the life to be Assured)
I do here by declare that the foregoing statements and answers are true and complete in every particular

Occupation

Address

Signature of witness

Signature of the proposer
(If the life to be assured is under 18 years)

Occupation

Address

Specimen Signature of the Life to be Assured

Specimen Signature of the Proposer

DECLARATION BY THE PROPOSER

I (name of the proposer) do hereby declare that the statements and answers under headings 1 to 7 of the proposal form have been given by me after fully understanding the questions and the same are true and complete in every particular and agree and declare that these statements and this declaration along with the statements made by the life to be assured under headings 8 to 25 of the proposal form and declaration relative thereto shall be the basis of the contract of assurance 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 all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

And I further declare that if after the date of submission of the Proposal but before the issue of First Premium Receipt (I) any change in the occupation of the life to be assured or any adverse circumstances connected with the financial position or general health of the life to be 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 to be 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.

Dated at On the date of , 2001

Signature of witness

Signature or thumb impression of the Proposer

Occupation

Address

If in this form the answers to the questions and/or signature(s) of the Proposer/Life to be Assured are/is in Hindi or any other Indian Language then proposer/Life to be Assured should declare in his own handwriting above his own signature(s) 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 the form:

Declarant's Name

Address

I hereby declare that I have fully explained the above questions to the proposer/Life to be assured and I have truthfully recorded the answers given by the proposer/ Life to be Assured

Signature

2. IN CASE THE PROPOSER AND/OR LIFE TO BE ASSURED ARE/IS ILLITERATE: The thumb impression of the proposer/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.

Declarant's Name

Address

I hereby declare that I have explained the contents of the proposal form to the proposer/life to be Assured in language and that I have read out to the Proposer/Life to be Assured the answers to the questions dictated by the Proposer/ Life to be Assured and that Proposer/Life to be Assured has affixed his thumb impression on the proposal form after fully understanding the contents thereof.

Signature

N.B: Rebate of premium shall be allowed only in accordance with details given in the prospectus or table of premium rates or as the case may be in the relevant document, and that an offer or acceptance of any other rebate shall be an offence under Section 41 of the Act

FOR MEDICAL CASES ONLY

I certify that the proposer/life to be assured has/have signed/put his/their thumb impression(s) in my presence after admitting that all the answers to Question Nos. 12 & onwards of the proposal form have been correctly recorded.

Signature or thumb impression of the Life to be Assured before Medical Examiner

Signature of the Medical Examiner

&y that the proposer/life to be assured has/have signed/put his/their thumb impression(s) in my presence after admitting that all the answers to Question Nos. 12 & onwards of the proposal form have been correctly recorded.
Signature or thumb impression of the Life to be Assured before Medical Examiner

Signature of the Medical Examiner