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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 where deferment period is 10 years or more under CDA/CAP Plan)
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.360(Rev.93)
Proposal No.	Branch

Agent Code Number	DO Code

Inward Number	Date

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

5. Is any other proposal on the life of the life to be assured now being made to or is any other proposal or an application for revival of a policy, on his life under consideration of his or any other office of the Corporation? If so which is the office and what is the amount?

6
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

7Please 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	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.
8 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?		(b) Deferred or declined?
(c) Accepted with an extra premium or lien?		(d) Accepted on terms otherwise than those proposed? If yes, state
If Yes, state Proposal/Policy No. Name of office and year

9 Family History of the	LIVING		DEAD
life to be assured	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.

10 FOR 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

11 Has any of the relations of the life to be assured, living o r dead, suffered from any hereditary or infectious disease like diabetes, insanity, epilepsy, gout, asthma, tuberculosis, cancer, leprosy etc?
12Has the life to be assured come in contact during the last three years, with any person suffering from tuberculosis, leprosy or any other infectious disease? If so, give details.
13(a) Is the life to be assured now in good health and free from any disease?
(b) Is the life to be assured of good constitution?
(c) Has the life to be assured any bodily defect or deformity? If so, give details.
(d) Has the life to be assured had (i) Small Pox or (ii) Successful vaccination if so, (iii) When?	i) ii) iii)
14(a) Has the life to be assured suffered from any illness or disease ? If so, give details.
(b) Has the life to be assured ever had any operation, accident or disease ? If so, give details
(c) Has the life to be assured ever had an Electrocardiogram, X-Ray or Screening, Blood, Urine or Stool Examination? If so, give details.
(d) Has the life to be assured ever been in any hospital, asylum or sanatorium for check-up, observation, treatment or any operation ? If so, give details.
15(a) Is the life to be assured a student ? If so, in which standard ?
(b) Do you wish to secure the premium Waiver Benefit in case of your death before the commencement of risk ?
16 Do you agree to the condition that the Policy if issued on basis of this Proposal will automatically vest in the life to be assured on the deferred date ?

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 day 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: Reduction in premiums allowed only in case of large sums assured and for yearly mode of payments of premiums in accordance with the details given in the prospectus. Offer of any rebate is an offence under section 41 of the Insurance Act, 1938.

Signature