J

LATEST COLOUR
PHOTO OF THE

llLIC
"oilQ'1'ilf ~ ~ ~
lire INIUIU,NC[ cottPOUTION or INOIA
FORM NO. 300 (Rev 2021)
PROPOSAL FOR INSURANCE ON OWN LIFE
(Not be used for Insurance on the lives of minors)
LIFE TO BE
ASSURED

Division: Branch Office:

INSTRUCTIONS TO LIFE TO BE ASSURED
1. This fonn is to be completed in BLOCK LETTERS by the Lle to be Assured.
2. This fonn contains 4 sections namely Section I: Details of L~e to be assured Section II: Proposed Plan, Section Ill: Details of
personal and family health and habits Section IV: Declaration
3. Please read all the questions carefully and fill up the details truthfully.
4. Please ensure that you affix your signatures in all the places as required. In certain places more than one signature is required.
This is in your own interest.
5. If the LWe to be Assured signs this proposal in vernacular or puts his/her thumb mpression upon It, then the respective
declaration must be completed. '
6. Answers should be legible. Questions should be answered in 'Yes' or 'No'. (Strokes/ dots/ dashes/ leaving the questions
unanswered will not be accepted). Details need to be provided in case of affinnative answers.
7. The LWe to be Assured must countersign any cancellation or alterations made in this fonn. White ink must not be Used

To be filled by agent:
'I -

1. D.O./CLIA Code No I Mentor code & Mobile number:

2. Agent's/Specified Person's/DSE's/Sup Agent's Name ,Code No & Mobile number":
3. Licence No:
4. Date of Expiry:
For Office Use Only:
Inward no: Date
Proposal no : Amt of Deposit : :_ B.O.C No: Date:

Section -1.: Details of the Life to be a·ssured

- - .
I.Personal Details
1 Name Prefix Fr;_.rame Middle Name
Mr./~ >~- L~
..,......, . . I ' , ,. .
~

2 Father's Full name U/ ~..(A I ~ - T / Y { ~ v ~ _..,_

3 Mother's Full Name <~
Male / F_ ,;::-__ , , 11;, u '-'endero
- -- ~

4 Gender
5 Marital Status (/ V ~--- ,,...,, , - Ji_
YlJ./1/....A.17-~
6 Spouse's Full name
7 Date of Birth I) ( I r~ t
/.Ji''1 :-(
8 Age•• - Years
** Depending upon the plan conditk>ns, Age last birthday/Age nearer birthday shall be applied for the calculation of premium
9 Place/ City of Birth M y (I vv--v--{_ L
(
10 Nature of Age Proof
Submitted
11 Nationality ~~A-~
II~ J
12 Citizenship ' _,,,,,/' < )~V -
13 Correspondence Address /_ ~
House No. ,~ "10 /.NvYv/.
City/ Town/ Villaoe V
' J t . ~ ~v- ~
District & State d 2 ~~
,;...,._..... V
Country /.,}
PIN Code 1(/_,1 ~ ~
Tel. No. with STD Code - I

14 Permanent Address
House No.
City/ Town/ Villaoe
•
\...
__, .
I _..,-
District & State
Country
PIN Code
Tel. No. with STD Code

1
15

16
Residential status Resident Indian/ Non Resident Indian/ Foreign National of
Overseas Citizen of India
Address outside India ( Applicable only for NRI/FN
IO/ OCI)
Indian Origin/ --
House No.
City/ Town/ Villaoe
District & State
Country
PIN Code

II KYC& PMLA
1 Are you Income Tax
Assessee
2 PAN Number
3 ID details( to be answered only if p
• In case of Aa last four d'
Proof of ldentit
ID number •
Ex i date of id
4 Address Proof Submitted
5 Are You Registered under
GST, if es ive GSTIN :
6 C KYC number ( Central
KYC Re istry)
} 'J
y
O t:i_
l-1. "1 1
~
, O
Ill Occupation
1 Educational qualification -
~ ,,,,---
J// ,1- !.!.~ .
-J
A
2 Present Occupation : "<-. ~ -r-
I .1
/1
"'00 7
.A
LJ-v • .YY ~ ' ' ~ ~Tlt "VV I f -y1
3 Source of Income y ' -
4 Name of the present

5
employer fNu._2/5
Exact Nature of duties
6 Length of service
7 Annual Income
8 To be answered if'employed in the Armed Forces
a Wing to which you belong
b Rank therein
C Date of last Medical
Examination
d Medical category after
medical examination
e Were you ever below A-1
category? If so, when?

IV Others
1 Is your occupation associated with any specific hazard or do

~
you
take part in hazardous activities or have hobbies that could
be
dangerous in any way? If yes, give details and submit
respective questionnaire .
2 Have you ever been or are currently being investigated, charge
sheeted, prosecuted or convicted or having pending charge
s in
respect of any criminal/civil offences in any court of law in India
or abroad ? If yes, oive details.
,('!V
3 Are you a Politically Exposed Person OR are you a family
member or close relative of Politically Exposed Person?
[As per RBI guidelines PEPs are the individuals who are or
been entrusted with prominent public functions in a foreign
have
'yM
.
country.]

2
 V us insurance taken from UC as well as from other
~xl 5t1ng l_nsurance: Please give details of your previo last 3 years)
insurers (including policies surrendered / lapsed during
it must
s, please use separate sheet in the same format .
Note: 1. l_f space is not sufficient for all existing policie
be duly signed by the life to be assure d has
proposal for insurance where a policy has lapsed or
2. Corporation nonnally does not entertain any fresh
the last 3 years.
been converted into paid up policy within

1 Policy Number I Lt I 'LfTD l m I+( v ~ 'J-~ I I

2 Name of the
Division/ Branch
Insure r/
~ -A-f31ll
-,- -~
I I
3 Plan and Term
Sum assured
1, ' t l ' . , . , ~
_cl)
1,' , nv• u ,../ - - - ~ t o - , ~ 7 I l
4
5 Term Rider Sum
Assured
;_ .(vJ:;,--
C-./

7 7 II
.,,-. /U- I I
Cl Rider Sum Assured
6
7 AB/ ADDS Sum
assured ~~ I I I I
__., I I
8 Date of Commencement tJ1 I 15) I :J1) '2--1 I I
~

~ I
Date of Revival
I/
.-:-./' I V
9 I
Wheth er accep ted at I
I
10
ordinary rate, if not give
details ~
lV<.-L P.L-· ~ I
11 Medical/ Non medical I 7
12 Wheth er lnforce '-4 ~
13 If not , Date of FUP/ / ___.Jh- I
I
Date. of surrender life made to L Yes/No Details
ation for_ reviva l of a policy ) on your
14 Has a proposal ( or an applic been
insure r ever
any office of the Corporation or to any other
give details.
a Withdrawn, Deferred, Dropped or Declined?, if yes
with extra Premi um or Lien?, if yes give details .
b Accep ted
than those propo sed?, if yes give details.
C Accepted on terms other
you during the past one year return ed any policy of the Corporation as
d Have
.
the same was not acceptable to you?, if yes give details
ation)
st of the life to be assured to avail the facility of nomin
VI Details of Nominee and a olntee (It is in the intere If Nomin ee is Relati onship Appo intee's
Name and address of % Age Relationship
to the signature as a
Nominee share with the life to minor
d appoi ntee's full nomin ee token of
be assure
name, age and conse nt
address

Id proof of Nominee/
Appointee
Id Number

VII Bank Details

Bank Account details:
a) Type of Account~Savis1. Cy.qent:
b) Your Account No : ()/V I O I 2- ~ L~ I fJ
-~ ~~ ~~ ~= =- --- --
c) MICA Code:.___.:77~-~ A,.-( ~----
d) IFS Code :.:--: ---'.: -:-~~ --=-: --i--- -'--=- L-:..~
__
e) Name and Addre ss of your bank: --=== ;___ _ _ _ _ _ _ _ _ _ _ _ _
Attach a hotoco or cancelled che._u_e_w~·~~... .:.t:;~

Mobile number of the life to be assured:

E mail id of the life to be assured:

d
Signature I Thumb impression of the life to be assure
3
 Section-II Proposed Plan

I Obiective of Insurance Saving / Risk Cover/ Savino and Risk Cover

**
II Whether proposal is under (please tick Individual life / Employer- Employee Scheme /HUF /MWP
relevant options)
** Note: If proposal is not under individual life, please submit relevant questionnaire/ annexure/supporting
documents along with the proposal form

Ill Please Tick the Riders which you want to avail along with the base plan as per the Plan conditions

1. LIC's New Term Assurance Rider

2. LIC' s New Critical Illness Benetit Rider
3. LIC's Premium Waiver Benefit Rider
4. LIC's Accident Benefit Rider (AB)
OR
LIC's Accidental death and Disability benefit Rider (AD&DB)

IV Plan, Sum assured and Rider selected by the Life to be assure ( Riders are subject to availability
under the selected Ian
a Plan, Term Sum Mode of Premium Term Rider Critical Accident If policy is to
& Premium Proposed Payment Sum illness sum benefit sum be dated back
paying Term (Basic Sum (Yly/Hly/Qly/ SSS pro osed proposed (if proposed (if indicate date
ured) /NACH/ Single) opted) o ted)

b Applicable to Police Personnel if LIC's Accide t Benefit Rider/ LIC's A

Death And Disability Benefit Rider is opted for:

i. Whether you are engaged in police duty in any police organization other
than paramilitary force?lf "Yes",
ii. Whether ou wish to avail the AB/AD& DB rider while on olice dut ?

1? Df
C For SSS Policies:
i. Paying authority code and Dept No h r,,. v,1 1
ii. Bad e or SR No D ~-l C) :)

V. To be answered only If proposing f.or "LIC's Premium Waiver Benefit Rider " in case of Ins
Minor Life

Premium Waiver Benefit under this rider shall be equal to waiver of premiums payable under the Base Policy falling
due on and after the date of death of Proposer till the expiry of rider term.
However, premiums in respect of any riders, if opted for, other than this rider under the base policy shall not be waived
and continue to be paid as per respective rider conditions.
Further if premium paying term of the base policy exceeds the rider term all the premiums due under the base policy
from the date of expiry of "LIC's Premium Waiver Benefit Rider" shall be payable by the Life Assured as per the
terms and conditions of the Base policy.

Do you agree with the above Yes/ No

Note: Proposal shall be considered for LIC's Premium Waiver Benefit Rider only , if your answer to the above
question Is "Yes"

VI. To be answered only If proposing under "LIC's Aadhaar Stambh" or" LICs Aadhaar Shila"
a. Total existing (excluding the proposal under consideration) sum assured under LIC's Aadhaar
Shila/ LIC's Aadhaar Stambh : _ _ _ __
b. Is your life being proposed simultaneously under the same plan? Yes/No.
If "Yes", give details : .
Note: The total Sum Assured under LIC's Aadhaar Stambh or LIC's Aadhaar Shila on an individual should not
exceed Rs.31akhs.

4
 Jeevan Amar
VII. To be answered onIYIf applicable as per Plan specifications and for
g):
category do you o apply? (Tick one of the followin
a. Under Whichoke
I) Sm r
ii) Non- Smo ·-- -~
ings of Urine Cotlnlne Test.
Note: Non- smoker wm be offered only on the basis of find
th (by ticking ( ~)
ti : Plea se sele ct one of the options for Sum Assured on Dea
.....-n" "" B n
b. . ing upon your specific needs:
!n the appropriat box) depend ure d on Death shall be an amount equ
al to Basic Sum ~== --...: ::;;_ --,
", whe re Sum Ass
Option I: "Level Sum Assuredstant throughout policy term.
Assured and shall remain con
remain equal to Basic Sum
Ass ured ", whe re Sum Assured on Death shall each
Option II: "Increa sing Sum by 10% of Basic Sum Assured
d till com plet ion of fifth poli cy year. Thereafter, it increases e the Bas ic Sum Ass ured.
Assure omes twic
till fifteenth policy year till it bec Death;
year from the sixth policy year info rce policy till the end of policy term; or till the Date of
incr eas e will con tinu e und er an cy yea r and onw ards,
This enth poli
whichever is earlier. From sixte cy term ends.
or till the fifteenth policy year, con stant i.e. twic e the Basic Sum Assured till the poli
Ass ure d on Dea th rem ains
the Sum

ls
VIII Simultaneous Pro osa an application
Is you r life now being prop osed for another assurance or
a or any othe r prop osal under
tor revival of a policy on your life tion or to any other insurer?
Cor pora
consideration in any office of the
If yes, give details
dren? If
usly on the lite of spouse and chil
b Whether proposed simultaneo
es, ive details
Ian conditions
IX Settlement tlon As r ents" : Ye
tion to take Maturity Benefit in Instalm : Y
Do you wish to avail "Op th Ben efit In Inst alments"
take Dea
Do you wish to avail "Option to par t of the proposa for
which forms a
If 'Yes', Kindly fill the addendum
psum to
of payment of claim from lum
e: You will hav e the opt ion of altering the mode of receipt of claim.
Not Int
ln the olic duration till the
Instalment and vice versa dur

tal: Y/N
X Are you registered with LIC Por __ osal
_
If yes, give Custom er ID _ _ Portal after completion of this prop
visit our site ww w.licindia.in and register yourself with LIC
It not, Please
.
to avail the ben fit of e services

Sign -........::__,..-

ails of health I habits

Section- 111: personal and family det

Personal Health Height Weight

) and weight ( in Kgs) ( without
a Please state exact height ( in ems
shoes tor ~ny
consult a Medical Practiti~ner
b During the last five years did you e than a week ? If es, Ive details
mor
ailment r uirin treatment for e'?'
e you ever bee n adm itted to any hospital or nu~sing hom
c Hav or ope ration? If yes, give
, treatment
general check up, observation
details lth
place of work on grounds of hea
d Have you remained absent from details
, give
durin the last 5 years? If yes 5
e Are you suffering from or have you ever suffered or undergone investigation in the past or have you been
advised to under o investi ation or treatment for the followin ailments:
Diseases Y/ Diseases
1. Lungs/ Respiratory Disease/ Persistent 2. Hypertension, Hypotension, rheumatic fever,
cough, asthma, bronchitis, pneumonia, spitting pain in chest, breathlessness, palpitation, any
of blood etc disease of the heart or arteries?
3. Peptic ulcer/colitis, jaundice, anaemia, piles, 4. Any disease of kidney /prostate or urinary
dysentery, or any other disease of the s tern?
stomach, liver, spleen, gall bladder or
ancreas/ di estive disorder
5. Paralysis/epilepsy/ insanity/ tremors, 6. Hernia/hydrocele, varicocele, fistula, varicose
numbness, double vision, dizzy or fainting ·ns, ,filariasis, gonorrhoea, syphilis or any
spells/ head Injury/ insomnia/ nervous other venereal disease?
breakdown / any other disease of the brain or
the nervous s stem
7. Cancer/leukemia/lymphoma/ tumour I cyst/ . Any disease of ear, nose, throat or eyes,
Any other growth / lumps/ blood disorder including defective sight or hearing and
/enlar ed glands dischar e from the ears
9. Endocrine disorders such as Diabetes, . Bone/ Joint' Spine Disease/ Arthritis
Goitre, Thyroid etc or have you ever passed
sugar, albumin, us or blood in urine
11. Mental Disorder (Depression/ Anxiety, 12. Chronic infections- Tuberculosis/ pleurisy/
etc.. Skin Disease/ skin eru tion/ Le ros .
13. Hepatitis or AIDS & HIV related condition 14. Any Operation, accident or injury/ any bodily
defect or deformit .
15. An other disease?
f If answer to any of the questions mentioned in 'e' above is yes, please give details as below ( If hospitalized
,
enclose the dischar e summa and all investi ation rs alon with the ro sal form. •
Nature of disease/ Date of Fully recovered Still on treatment (YIN), If Name and address
illness Diagnosis (YIN) Yes give details of of Doctor/ Hospital
treatment

II Personal Habits
Do you smoke/consume or have you ever smoked/consumed the Y/N, If yes, quantity If stopped,
following (a,b,c) consumed and duration since how many
months
a. Alcoholic drinks
b. Narcotics
c. An other dru s, If es, which one
d. Do you smoke/ consume or have you smoked/consumed
tobacco in any form (Tobacco product includes but not limited
to cigars, cigarettes, beedis, chewable tobacco like Gutkha,
flavored paan masala, etc.) in the past 60 months. (in sticks
/ ackets/ sachets/da or ms /da

I III I What has been your usual state of health?

IV Family details
1 Have your parents/ spouse/ Partner I children and/or any of your
relations ever suffered from or died of heart disease, stroke, high

~
blood pressure, diabetes mellitus, cancer, kidney disease or any
hereditary disorders, Insanity, or any contagious diseases such as
tuberculosis ,hepatitis, AIDS/ HIV etc.? If yes, please specify
a. Name of the disease
b. Relationship with the life to be assured and
C. date / year of death

2 Family History
I Living I Dead
6
 Aoe State of health Age at death Year/cause of death
Father
Mother
Brothers
living
Dead
Sisters
Living .• ~ ..
-:
•..,
Dead
Spouse
Children
Living
Dead

V
a
For Female Proponents only
Are you pregnant now?
. A
I
b Date of last delivery I
C Have you had any abortion or miscarriage or Cesarean section? If so,
give details
I I

d H~ve you ever consulted a gynecologist or undergone any investigation,

treatment for any ovnaec ailment? (If yes, give details)
I
/\1 k' I I
e Husband's details
Husband's full Name
f I
His Occupation
His Annual Income
f Details of Husband's Insurance
Name of branch/ Division/ Name of the Sum Plan & Present status of
Policy number the policy
insurer ( if other than UC) _ from where Assured Term
policy has been taken

(\ /\ '
.A""' I\..,.I \ L .,..--
I -l
-
~ ------ l

Section IV: Declaration

DECLARATION BY THE PROPOSER

being proposed to be assured,
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ the person whose life is herein
answers have been given by me after fully understanding the
do hereby declare that the foregoing statements and
and the same are true and complete in every particular and that I have not withheld any information and I do
questions
of the contract of assurance
hereby agree and declare. that these statements and this declaration shall be the basis
be contained therein the said
between me and the Life Insurance Corporation of India and that if any untrue averment
per provisions of Section 45 of the Insurance Act, 1938 as amended from time to time.
contract shall be dealt with as
being in force prohibiting any
Not-withstanding the provision of any law, usage, custom or convention for the time
c center and/or employer, reinsurer/ credit bureau from divulging any knowledge or
doctor, hospital ,diagnosti etc.on the grounds of
nt , occupatio n, insurance , financial
information about me concerning my health or employme
7
11

Ptivacy, I , my heirs, executors, administrators and assigne

es or any other person or persons: having intereSt of any
kind whatsoever in the policy contract issued to me, hereby
agree that such authority , having such k~ooledge or
information, shall at any time be at liberty to divulge any
such knowledge or information to the Corporation, and the
Corporation to divulge the same to any Authorised Organi
sation / Institution / Agency/ and Government~! I Regulatory
Authority for the sole purpose of underwriting / investigation
/ risk mitigation / fraud control ~nd/or cla_1m settle~en~.
And I further agree that if after the date of submission of
the proposal but before the issue of First Premium Receip
any change in my occupation or any adverse circumstance t (1)
s connected with my financial position or the general
health of myself or that of any members of my family occurs
or (ii) if a proposal for assurance or an application for
~evival of a policy on my life made to any office of the Corpor
ation is withdrawn or dropped, deferred 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 accept
ance of assurance. Any omission on my part to do so shall
render this contract to be dealt with as per provisions of
to time. Section 45 of the Insurance Act, 1938 as amended from time

I undertake to inform the Corporation immediately of any

changes in KYC documents such as residence. I also give
my. con~ent !O share my data with Central KYC Registry
registry in this regard. and to receive phone calls , SMS/ E mail from Central KYC

I understand that the Corporation reserves the right to accept

proposal for life insurance . /Postpone/ drop/ decline or offer alternate terms on this

I hereby give my consent to receive phone calls, SMS/E

mail on the below mentioned registered number/ E mail
a~r~s s from I ?n ~half of the Corporation with respec
t to my life insurance policy/regarding servicing of insuran
pollc1es/enhancmg insurance awareness/ notifying about ce
the status of Claim etc
I ~lso understand th~t the premium and benefits under the
with the laws as applicable from time to time. policy are subject to taxes / duties/ charges in accordance

-------, t-,.L,-, ;c..___ ,.--_ on the _ _ _ day of _ _ _ _ 20

Address- -
-- ~--
1. Declaration by the person fitting In the fonn (In case fonn
Proposal Fonn or In case the proposer Is person with Is filled up/signed In a language different from that of the
disability (PWD} where he/she ls not able to fill the propos
form himself/ herself.) al

"I hereby declare that I have fully explained the above questions
by the proposer and proposer has affixed the thumb
to the
proposer and I have truthfully recorded the answers given
impression/ signature below fter fully understaroing the content
thereof." s
Name of the Declarant:_ _ _ _ _~

Address of the Declarant:_ _ _ _ __

"I certify that the contents of the form have been fully explained
to me by (Name, Designaton, occupation) Mr. I
Ms.:_ _ _ _ __

Signature or Thumb impression of the life to be assured

2.ln case the Proposer Is llllterate, his/her th001b Impres
sion should be attested by a person of standing whose
Identity
can easily be established, but ooconnected with the Corpor
ation and this declaration should be made by him.

8
 proposer n
I have full e . the proposal form to the
"I hereby declare that stions and contents of
Y xplained theh aboff've que . .
r fully understanding the con
tents
_ _ _ I uag e, and that the proposer as a ,xed the thumb 1mpress,on above afte
__
thereof...

Name oft
Address f the Declarant: - - - - - - - -

URANCE ACT.1938 expiry of three years

SECTION 45 OF THE INS
. . .
led in que stio n on any ground whatsoever after the ment of risk or the
1 n?e sha ll be cal e of com me nce
f~ ) No polrcy of hfe ms~ra ance of the policy or the dat r.
, 1.e., from the date of issu late
om the d~te of the polr~y or the date of the rider to the policy, whichever is the date of issuance of the
date of ~ev1val. of !he policy led in que stio n at any time within three years from the rider to the policy,
may be cal or the date of
(2)~ policy of hfe insurance ncement of risk or the date of revival of the policy
or th_e dat e of com me
pol_icy ground of fraud : atives or nominees
whichever 1s later, on the ate in wri ting to the ins ured or the legal represent
shall have to communic ision is based.
Provi~ed that the in~urer the grounds and the materials on which such dec s committed
or ass,gnees of the ins ure d exp res sio n "fra ud" me ans any of the following act
tion , the a life ins urance
purpose of this sub sec the insurer or to induce the
insurer to issue
Explanation I - For the the inte nt to dec eiv e
nt, with
by the insured or by his age s not believe to be true;
policy:
of tha t wh ich is not true and which the insured doe the fact;
fac t
(a) The suggestion, as a of a tact by the insured having knowledge or belief
of
nt
(b) The active concealmedeceive ; and
(c) Any other act fitted to lares to be fraudulent. ess
on as the law specially dec the insurer is not fraud, unl
(d) Any such act or omissi fac ts like ly to affe ct the assessment of the risk by insure d or his agent,
nce as to dut y of the
Explanation II - Mere sile e are such that regard being had to them, it is the
cas ak.
the circumstances of the in itse lf, equ iva len t to spe
insurance policy on the
or unless his silence is, urer shall repudiate a life
keeping silence to speak, ctio n (2), no ins to the best
g contained in sub -se of a material fact was true
(3) Notwithstanding anythin can prove that the mis-statement of or suppression -sta tement of
d ss the fact or that such mis
ground of fraud it the insure or that there was no deliberate intension to suppre
ief
of his knowledge and bel fact are within the knowledge of the insurer: es, in case the policyholder
is
or sup pre ssion of a ma teri al
d, the onu s of dis pro vin g lies upon the beneficiari
Provided that in case of frau
d for the purpose of the
not alive. neg otia tes a con trac t of insurance shall be deeme
o solicits and
Explanation: A person wh be agent of the insurer. the date of issuance of the
form ation of the con trac t, to
led in que stio n at any time within three years from the rider to the policy,
may be cal the date of
(4) A policy of lite insurance ment of risk or the date of revival of the policy or the life of
icy or the dat e of com mence sup pre ssio n of a fac t ma terial to the expectancy of or •
pol t any sta tem ent of or the pol icy wa s issu ed
ground tha is of which
whichever is later, on the other document on the bas
ure d wa s incorr ect ly made in the proposal or
the ins entatives or nominees
revived or rider issued: nic ate in wri ting to the insured or the legal repres icy of life insurance
shall have to commu ich such decision to repudi
ate the pol
Provided that the insurer gro unds and materials on wh
of the ins ure d the
or assignees or suppression of a materi
al
is based: udi atio n of the pol icy on the ground of misstatement udiation shall be paid to the
e of rep e of rep
Provided further that in cas d, the premiums collected on the policy till the dat a period of ninety days from the
frau hin
tact, and not on ground of atives or nominees or assignees of the insured wit
ent
insured or the legal repres sidered
ssion of fact shall not be con
date of such repudiation. of this sub -se ctio n, the mis-statement of or suppre s Is on the insurer to show that
poses onu
Explanation - For the pur ertaken by the Insurer, the n Issued to the insured.
ct bearing on the risk und bee
material unless it has a dire of the said fact no life Insurance policy would have he is entitled to do so,
had the insurer been aware from cal ling for proof of age at any time if on
shall prevent the ins ure r s of the policy are adjusted
(5) Nothing in this section to be cal led in que stio n merely because the term
me d proposal.
and no policy shall be dee s incorrectly stated In the
age of the life insured wa
subsequent proof that the

URANCE ACT
ECTION 41

9
1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any
person to take out or
renew or continue an insurance in respect of any kind of risk relating to lives or property in India,
any rebate of the
whole or part of the commission payable or any rebate of the premium shown on the policy, nor
shall any person
taking out or renewing or continuing a policy accept any rebate, except such rebate as may
be allowed in
accordance with the published prospectus or tables of the insurer.

Provided that acceptance by an insurance agent of commission in connection with a policy of life
insurance taken
out by himself on his cmn life shall not be deemed to be acceptance of a rebate of premium within
the meaning of
this sub-section if at the time of such acceptance the Insurance agent satisfies the prescribed
conditions
establishing that he is a bonafide Insurance Agent employed by the insurer.

2) Any person making default in complying with the provisions of this section shall be liable for a
penalty which may
extend to ten lakh rupees.

10
 t Option (for Maturity Benefit)
Addendum to Proposal Form for Settlemen
(To be furnished by the Life Assured)

Proposal No.
/NO
Maturity Benefit) under the proposal ? YES
Do you wish to avail Settlement Option (for
the following:
If yes, please Tick/Strikeout (if not applicable)
10 / 15
1. Period for settlement option (in years): 5 / eds
ment Option (for Maturity Bene fit) is required for: Full / Part of the benefit proce
2. Whether Settle
the benefit proceeds:
If in part, specify the amount/ percentage of
-------------- ---
Absolute amount:
eds: -------------- ---
Percentage of benefit proce
early I Quarterly I Monthly
3. Mode of Instalment payment: Yearly I Half-Y
instalment amount_(as mentioned
required amount to ?d e the minimum
If the Net Claim Amount is less than the the claim proceed shall be paid in lump sum
below) as per the option exercised by the Proposer/life to be Assured,
only.

Minimum
Mode of Instalment Instalment amount
payment (Rs)

Monthly

Date & Place :

11
 Addendum to Proposal Form for Option to take Death Benefit In Instalments

(To be furnished by the Ute Assured)

Proposal No.

Do you wish to avail Option to take Death Benefit in Instalments under the proposal ? YES/ NO

If yes, please Tick/Strikeout (if not applicable) the following:

1. Period for Option to take Death Benefit in Instalments (in years): 5 / 10 / 15

2. Whether Option to take Death Benefit in Instalments is required for: Full / Part of the benefit proceeds
If in part, specify the amount/ percentage of the benefit proceeds:
Absolute amount: -----------------
Percentage of benefit proceeds: -------·---------
3. Mode of Instalment payment: Yearly/ Half-Yearly/ Quarterly/ Monthly

If the Net Claim Amount is less than the required amount to provide the minimum instalment amount (as mentioned
below) as per the option exercised by the Proposer/Life to be Assured, the claim proceed shall be paid in lump sum
only.

Mode of lnstclllment Minimum instalment

amount (Rs)

Date & Place :

Signature / T

12