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Proposal Form (Rev-2024) COLOUR COLOUR

For PHOTO OF PHOTO OF
LIC’s Index Plus THE THE LIFE TO
PROPOSER BE

Division: Branch Office:

“IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER”
LIC’sIndex Plus is a ULIP plan which is different from the traditional policy in the sense that it is subject to
market risk.
LIC does not authorize its agents/intermediaries, staff and officials to express their opinion on the future
performance of the “ULIP” fund, excepting the prescribed illustrative rate of 4% and 8% growth.

INSTRUCTIONS TO FILL THE PROPOSAL FORM

1. This form is to be completed in BLOCK LETTERS by the Life to be assured/ Proposer.
2. Please read all the questions carefully and fill up the details truthfully.
3. If the Life to be assured /Proposer signs this proposal in vernacular or puts his/her thumb impression upon it, then
the respective declaration must be completed.
4. 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 affirmative answers.
5. The Proposer/ Life to be assured must countersign any cancellation or alterations made in this form. White ink
must not be used.

To be filled by Agent/ Intermediary

1. D.O./CLIA /Chief Organizer/ Intermediary Agency Code No &Mobile number
2. Agent’s/Specified Person’s/DSA’s/Sup Agent’s Name , Code No & Mobile number
3.Licence No/ Registration No4 Date of Expiry (DD/MM/YYYY):

For Office Inward no : Date(DD/MM/YYYY):Proposal no : B.O.C No:

Use Only Date(DD/MM/YYYY) : Amt of Deposit (Rs) :

Section -I :Details of the Life to be assured / Proposer

I Personal Details
1 Customer ID
2 C KYC number
3 ABHA number
4 Name Prefix First Name Middle Name Last Name

5 Father’sFull name First Name Middle Name Last Name

6 Mother’s Full Name First Name Middle Name Last Name

7a Name of the
Proposer in case of
minor life and
Employer- employee
Scheme
b Relationship of
proposer with life to
be assured
8 Gender Male / Female / Transgender#

# LIC’s Index Plus is allowed to Transgender.

9 Marital Status
10 a. Date of Birth ____/______/________ Age___ b. Age proof submitted:
(DD/MM/YYYY) yrs
11 Proof of Aadhar Driving License Id Number (In case of
Identity: Voter Id Passport Aadhar only last four
digits)
12 Permanent Address as per above Proof of Identity
House No../Building Name /
Street
Town/ Village / Taluka
City/ District
State &Country
PIN Code
13 Correspondence / Current Address if different from above ( Proof to be submitted)
House No../Building Name /
Street
Town/ Village / Taluka
City/ District
State &Country
PIN Code
14 Contact details Mobile Number WhatsApp Mobile Email id
No.
15 Nationality

16 Residential status Resident Indian / Non Resident Indian*/Foreign National of Indian Origin*
*NRI Questionnaire mandatory
Details of Life to be Details of Proposer
assured
17 Is your country of Tax Residency outside India ? Yes / No Yes / No
(If yes, fill the Self Certification Form )
18 Are you an Income Tax assessee Yes / No Yes / No
19 Permanent Account Number (PAN)

20 If Registered under GST, please give GSTIN

21 Educational qualification / class in which studying

22 Present Occupation / Source of Income

23 Name of the present employer

24 Exact Nature of duties (please specify if engaged in

police duty)
25 Length of service

26 Annual Income (Rs)

27 Are you employed in the Armed Forces (If Yes,

submit relevant questionnaire)

II Others
1 Is the life to be assured’s occupation associated with any specific hazard or does the
life to be assured 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/ life to be assured ever been or are currently being investigated, charge
sheeted, prosecuted or convicted or having pending charges in respect of any
criminal/civil offences in any court of law in India or abroad ? If yes, give details.
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 have been entrusted with prominent public functions bya foreign country].
III Existing Insurance: Please give details of your previous insurance taken from LIC as well as from other
insurers (including policies surrendered / lapsed during last 3 years)
Note:
1. If space is not sufficient for all existing policies, please use separate sheet in the same format. It must be duly
signed by the Life to be assured
2. Corporation normally does not entertain fresh proposal for insurance where a policy has been lapsed or
converted into paid up policy within the last 3 years.
Proposal Form- LIC’s Index Plus
1 Policy Number

2 Name of the Insurer/ Division/

Branch
3 Plan and Term

4 Sum assured (Rs)

5 Term Rider Sum Assured (Rs)

6 CI Rider Sum Assured (Rs)
7 AB/ ADDB Sum assured (Rs)
8 Date of Commencement
(DD/MM/YYYY)
9 Date of Revival(DD/MM/YYYY)
10 Whether accepted at ordinary
rate, if not give details
11 Medical/ Non medical
12 Whether Inforce (Yes/No)
13 If not , Date of FUP/ Date of
surrender(DD/MM/YYYY)
14 Has a proposal ( or an application for revival of a policy) on your life made to
a any office of the Corporation or to any other Insurer ever been Accepted with
extra or modified terms, Withdrawn, Deferred, Dropped or Declined?, if yes give
proposal number& branch / policy number / Name of Insurer
b Have you / Life to be assured during the past one year returned any policy of
the Corporation as the same was not acceptable ?, if yes give givepolicy
number.

IV (a). If the Proposal is on the life of Minor or Major student, please give below the particulars of all the assurance
in full force on the lives of parents, brothers and sisters of Life to be assured
Relationship Policy No Total Sum Assured
Father
Mother
Brothers
Sisters
(b). Whether all the children are insured equally?
If No, please mention reason for the same
Note: (Please give details of all questions in the space provided for the same.). If space is insufficient, attach a
separate sheet duly signed by Proposer

V Details of Nominee and Appointee ## It is in the interest of the Life to be assured to avail the facility of
nomination. The nomination can be Single or Multiple. Please give % share in case of multiple nomination)
Name of % DOB Age Relationship with Mobile Email ID Address of
Nominee share (in yrs.) the Llife to be no. nominee
assured

##Q.Vto be filled only if Life to be assured is major

Nominee Bank details:
Bank name Bank Account no. IFSC code

Appointee Details: (applicable in case of minor nominee)

Name of DOB Age (in Relationship Mobile no Email ID Address of Appointee’s signature
Appointee Yrs) with the Appointee or thumb impression
Nominee as token of consent

VI Bank Details (If Life to be assured is minor, give bank details of proposer)
a) Type of Account-Savings / Current b) Your Account No :________________________
c) IFS Code:_____________________________ d) Name of your bank: ____________________________
{Attach a cancelled cheque leaf (along with copy of bank passbook if name is not printed on the cheque leaf)}
Proposal Form- LIC’s Index Plus
 Section–II: Proposed Plan Details

I Objective of Insurance Saving / Risk Cover/ Saving 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

IIIa Policy Term b. Mode of Premium Payment Yly/ Hly/Qly/Monthly(NACH)

c Installment Premium (In figures) Rs.
d Installment Premium (In words) Rs.
e 7 times of Annualized Premium
Basic Sum Assured For Age at Entry 0 years to 50 years choose
OR
any one the following Basic Sum Assured options
10 times of Annualized Premium
Basic Sum Assured For Age at Entry 51 years to 60 years 7 times of Annualized Premium
f Does Life to be assured wish to opt for LIC’s Linked Accidental Death
Yes/ No
Benefit Rider ?
g If “Yes” , Sum Assured under LIC’s Linked Accidental Death Benefit Rider Rs.
h If engaged in police duty do you wish to avail AB/AD&DB Rider while on
police duty Yes/ No
i Does Life to be Assured wish to avail “Settlement Option to take Death
Benefit In Instalments” Yes/ No
If ‘Yes’, Kindly fill the addendum which forms a part of the proposal form

IV Fund Selected FLEXI GROWTH FUND / FLEXI SMART GROWTH FUND(See the information below)
Fund Type Investment in Short-term Investment Details and objective of the fund for Risk SFIN No.
Government/ investments in Listed risk /return Profile
Government such as Equity
Guaranteed money Shares
Securities/ market
Corporate instruments
Debt
0% to 20% 0% to 40% 40% to To provide long term capital Very ULIF00510
Flexi 100% appreciation through investment High Risk /11/23
Growth primarily in select stocks which are a LICULIPFL
Fund part of NSE NIFTY100 Index. X512
Flexi 0% to 20% 0% to 40% 40% to To provide long term capital Very ULIF00610
Smart 100% appreciation through investment High Risk /11/23
Growth primarily in select stocks which are a LICULIPFS
part of NSE NIFTY50 Index. G512
Fund
For further details, you can refer to the Sales Literature and/or Policy Document of this plan available on our website
ww.licindia.com

V Simultaneous Proposals
a Is the life to be assured now being proposed for another assurance or an Y/N
application for revival of a policy or any other proposal under consideration in
any office of the Corporation or to any other Insurer?
If yes, give Proposal no. / Policy no. and Branch Code
b Whether proposed simultaneously on the life of spouse/ children/ parents ? Y/N
If yes, give Proposal no. and Branch Code
VIa Do you wish to avail the physical policy document?
b Please give EIA (e-Insurance Account) no. if available

Section- III:Personal and family details of health /habits ofLife to be assured

I Personal Health
a Please state exact height and weight ( without shoes) Height( in cms) Weight( in Kgs)
b During the last five years did the Life to be assured consult a Medical Practitioner Y/N
for any ailment requiring treatment for more than a week ? If yes, give details
c Has the Life to be assured ever been admitted to any hospital or nursing home for Y/N
Proposal Form- LIC’s Index Plus
 general check up, observation, treatment, accident, injury or operation? If yes, give
details
d Has the Life to be assured remained absent from place of work on grounds of Y/N
health during the last 5 years? If yes, give details
e Is the Life to be assured suffering from or has the Life to be assured ever suffered or undergone investigation in
the past or has the Life to be assured been advised to undergo investigation or treatment for the following
ailments:
Diseases Y/N Diseases
1. Lungs/ Respiratory Disease / Persistent 2. Peptic ulcer/colitis,
cough, asthma, bronchitis, pneumonia, jaundice,Hepatitis,anaemia, piles, dysentery, or
Tuberculosis/, pleurisy / spitting of blood,/Covid any other disease of the stomach, liver, spleen,
19etc gall bladder or pancreas/ digestive disorder
3.Hypertension, Hypotension, rheumatic fever, 4. Endocrine disorders such as Diabetes,
pain in chest, breathlessness, palpitation, any Goitre, Thyroid etc or have you ever passed
disease of the heart or arteries? sugar, albumin, pus or blood in urine
5. Any disease of kidney /prostate or urinary 6. Bone / Joint/ Spine Disease/ Arthritis /
system? varicose veins /any bodily defect or deformity
7. Any disease of ear, nose, throat or eyes, 8. Cancer/leukemia/lymphoma/ tumour / cyst/
including defective sight or hearing and Any other growth / lumps/ blood disorder
discharge from the ears /enlarged glands
9.Paralysis/epilepsy/ insanity/ tremors, 10. Chronic infections- Skin Disease/ skin
numbness, double vision, dizzy or fainting eruption/ Leprosy / ,filariasis, gonorrhoea,
spells/ head Injury / insomnia/ nervous syphilis or any other venereal disease or
breakdown / Mental Disorder (Depression/ AIDS&HIV related condition
Anxiety, etc.). / any other disease of the brain
or the nervous system
12. Any other disease?
11. Hernia/hydrocele, varicocele, fistula
f If answer to any of the questions mentioned in ‘e’ above is yes, please give details as below ( If hospitalized ,
enclose the discharge summary and all investigation papers along with the proposal form.)
Nature of disease / Date of Fully recovered Still on treatment (Y/N), If Name and address
illness Diagnosis (Y/N) Yes give details of of Doctor/ Hospital
(DD/MM/YYYY) treatment

II Personal Habits
Does the Life to be assured smoke/consume or has ever Y/N, If yes, quantity If stopped, since
smoked/consumed the following consumed and duration how many months
a. Alcoholic drinks
b. Narcotics
c. Any other drugs, If yes, which one
d. Tobacco* in any form in past 60 months.(in sticks
/packets/sachets or gms /day)
* Tobacco product includes but not limited to cigars, cigarettes, beedis, chewable tobacco like Gutkha,
flavoured paan masala, etc.

III Family History(Please mention specifically if suffering 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)

Living Dead
Age (in Yrs) State of health Age at death (in Yrs) Year and cause of death
Father
Mother
Brothers
No.
Sisters
No
Spouse
Children
No
Proposal Form- LIC’s Index Plus
IV For Female Life to be Assured only
a Is Life to be Assured pregnant now?
b Date of last delivery (DD/MM/YYYY)
c Has Life to be Assured had any abortion or miscarriage or Cesarean
section? If so, give details
d Has Life to be Assured ever consulted a gynecologist or undergone any
investigation, treatment for any gynaec ailment? (If yes, give details)
e Husband’s details
Husband’s full Name
His Occupation
His Annual Income
f Details of Husband’s Insurance
Policy number Name of branch/ Division/ Name of the Sum Plan & Present status of
insurer ( if other than LIC) from where Assured Term the policy
policy has been taken

Section IV: Declaration

DECLARATION BY THE LIFE TO BE ASSURED

I ___________________________________________ the person whose life is herein being proposed to be assured,

do hereby declare that the foregoing statements and answers 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 and I do
hereby agree and declare that these statements and this declaration shall be the basis of the contract of assurance
between me and the Life Insurance Corporation of India . And I further agree that if after the date of submission of the
proposal but before the issue of First Premium Receipt (i) any change in my occupation or any adverse
circumstances 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 revival of a policy on my life made to any office of
the Corporation 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 acceptance of assurance. Any omission on my part to do so shall render this contract to be dealt with as per
provisions of Section 45 of the Insurance Act, 1938, and that if any untrue averment be contained therein the said
contract shall be dealt with as per provisions of Section 45 of the Insurance Act,1938 as amended from time to time.

Not-withstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any
doctor, hospital, diagnostic center and/or employer, reinsurer/ credit bureau from divulging any knowledge or
information about me concerning my health or employment , occupation, insurance , financials etc. on the grounds of
privacy, I , my heirs, executors, administrators and assignees 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 knowledge 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 Organisation / Institution / Agency / and Governmental / Regulatory
Authority for the sole purpose of underwriting / investigation / risk mitigation / fraud control and/or claim settlement.

I am aware that if the information on my Tax Residency is found to be false or untrue or misleading or
misrepresenting, I may be held liable for it. I also undertake to inform the Corporation of any change in my Tax
Residency status.

I undertake to inform the Corporation immediately of any changes in KYC documents such as residence. I also give
my consent to obtain and share my data from / with Central KYC Registry and to receive phone calls , SMS/ E mail
from Central KYC registry in this regard.
I understand that the Corporation reserves the right to accept /Postpone/ drop/ decline or offer alternate terms on this
proposal for life insurance .

I hereby give my consent to receive phone calls, SMS/whatsapp messages, E mail on the below mentioned
registered number(s)/ E mail address from / on behalf of the Corporation with respect to my life insurance
policy/regarding servicing of insurance policies/ notifying about the status of Claim

I understand that if I have deposited “application money” as a token consideration under this proposal for insurance,
the closing NAV of the date of completion only will be applied for allotment of units.

Proposal Form- LIC’s Index Plus

I also understand that the premiums, charges and benefits under the policy are subject to taxes / duties/ charges in
accordance with the laws as applicable from time to time.

Dated at ____________________ on the _______ day of __________ 20

Signature or Thumb impression of Witness Signature or thumb impression of the Life to be assured

Name, Occupation & Address:

Declaration by the Proposer in case of Minor life

I.................................................(Name of the proposer) do hereby declare that the foregoing statements and answers
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 and I do hereby agree and declare that these statements and this
declaration 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 dealt with as per provisions of Section
45 of the Insurance Act,1938 as amended from time to time.

Not-withstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any
doctor, hospital, diagnostic center and/or employer, reinsurer/ credit bureau from divulging any knowledge or
information about the life to be assured concerning the health, insurance , financial etc. on the grounds of privacy, I ,
on behalf of myself, the life to be assured, our heirs, executors, administrators and assignees or any other person or
persons, having interest of any kind whatsoever in this policy contract issued on the life to be assured, hereby agree
that such authority , having such knowledge 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 Organisation
/ Institution / Agency / and Governmental / Regulatory Authority for the sole purpose of underwriting / investigation /
risk mitigation / fraud control and/or claim settlement.

And I further agree that if after the date of submission of the proposal but before the issue of First Premium Receipt any
change in the general health of the life to be assured or that of any members of his family occurs, I shall forthwith
intimate the same to the Corporation in writing to reconsider the terms of acceptance of assurance. Any omission on
my part to do so shall render this contract to be dealt with as per provisions of Section 45 of the Insurance Act, 1938
as amended from time to time.

I am aware that if the information on my Tax Residency is found to be false or untrue or misleading or
misrepresenting, I may be held liable for it. I also undertake to inform the Corporation of any change in my Tax
Residency status.

I undertake to inform the Corporation immediately of any changes in KYC documents such as residence. I also give
my consent to obtain and share my data from / with Central KYC Registry and to receive phone calls , SMS/ E mail
from Central KYC registry in this regard
I understand that the Corporation reserves the right to accept /Postpone/ drop/ decline or offer alternate terms on this
proposal for life insurance .

I hereby give my consent to receive phone calls, SMS/whatsapp messages, E mail on the below mentioned
registered number(s)/ E mail address from / on behalf of the Corporation with respect to my life insurance
policy/regarding servicing of insurance policies / notifying about the status of Claim.
I further declare that I have discussed my financial standing with the agent/intermediary. I have been informed about
the risk profile of the ULIP plan(s) and fund(s). In consultation with the agent/intermediary, I have taken a personal
and independent decision in an informed manner to go for the Plan and Fund which I have chosen.

I understand that if I have deposited “application money” as a token consideration under this proposal for insurance,
the closing NAV of the date of completion only will be applied for allotment of units.
I also understand that the premiums, charges and benefits under the policy are subject to taxes / duties/ charges in
accordance with the laws as applicable from time to time.

Dated at ................................................on the ...........................day of ..........................20……

Signature or Thumb impression of Witness Signature of the Proposer

Proposal Form- LIC’s Index Plus

Name___________________
Occupation_______________
Address_________________

1. Declaration by the person filling in the form (In case form is filled up/signed in a language different from
that of the Proposal Form or in case the Proposer is person with disability (PWD) where he/she is not
able to fill the proposal form himself/ herself.)
“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 and Proposer has affixed the thumb impression/ signature as below after fully
understanding the contents thereof.”

Name and Address of the Declarant:________________ Signature:____________________

“I certify that the contents of the form have been fully explained to me by (Name, Designation, occupation) Mr. /
Ms.:________________.

Signature or Thumb impression of the Proposer/ Life to be assured

2. In case the Proposer is illiterate, his/her thumb impression should be attested by a person of standing
whose identitycan easily be established, but unconnected with the Corporation and this declaration
should be made by him/her.

“I hereby declare that I have fully explained the above questions and contents of the proposal form to the proposer
in ______________language, and that the Proposer has affixed the thumb impression above after fully
understanding the contents thereof.”

Signature ____________________
Name and Address of the Declarant: ________________

SECTION 45 OF THE INSURANCE ACT,1938

(1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years
from the date of the policy, i.e., from the date of issuance of the policy or the date of commencement of risk or the
date of revival of the policy or the date of the rider to the policy, whichever is later.
(2)A policy of life insurance may be called in question at any time within three years from the date of issuance of the
policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy,
whichever is later, on the ground of fraud :
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees
or assignees of the insured the grounds and the materials on which such decision is based.
Explanation I - For the purpose of this sub section, the expression “fraud” means any of the following acts committed
by the insured or by his agent, with the intent to deceive the insurer or to induce the insurer to issue a life insurance
policy :
(a) The suggestion, as a fact of that which is not true and which the insured does not believe to be true;
(b) The active concealment of a fact by the insured having knowledge or belief of the fact ;
(c) Any other act fitted to deceive ; and
(d) Any such act or omission as the law specially declares to be fraudulent.
Explanation II – Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless
the circumstances of the case are such that regard being had to them, it is the duty of the insured or his agent,
keeping silence to speak, or unless his silence is, in itself, equivalent to speak.
(3) Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the
ground of fraud if the insured can prove that the mis-statement of or suppression of a material fact was true to the best
of his knowledge and belief or that there was no deliberate intension to suppress the fact or that such mis-statement of
or suppression of a material fact are within the knowledge of the insurer:
Provided that in case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is
not alive.
Explanation: A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the
formation of the contract, to be agent of the insurer.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance of the
policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy,
whichever is later, on the ground that any statement of or suppression of a fact material to the expectancy of the life of
the insured was incorrectly made in the proposal or other document on the basis of which the policy was issued or
revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees
or assignees of the insured the grounds and materials on which such decision to repudiate the policy of life insurance
is based:

Proposal Form- LIC’s Index Plus

Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material
fact, and not on ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the
insured or the legal representatives or nominees or assignees of the insured within a period of ninety days from the
date of such repudiation.
Explanation – For the purposes of this sub-section, the mis-statement of or suppression of fact shall not be considered
material unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show that
had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so,
and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on
subsequent proof that the age of the life insured was incorrectly stated in the proposal.
______________________________________________________________________________________________
In accordance with the applicable provision of Section 41 of the Insurance Act, 1938:
“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”
_____________________________________________________________________________________________
Various Sections of the Insurance Act, 1938 applicable to LIC to apply as amended from time to time
Please visit our site www.licindia.in and register yourself with LIC Portal after completion of this proposal to avail the
benefit of e services.

FOR MINOR LIVES ONLY F.NO.3293A

DECLARATION BY PARENT / GUARDIAN (In case Life to be assured is a Minor)

“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 surrender or for
any other reasons whatsoever before the policy has vested in Life to be assured, I shall utilize the moneys hereby
received for the benefit of the minor or his/her estate.”

Signature of Parent / Guardian:_____________

Signature or Thumb impression of Witness:____________________
Name:_______________________________
Occupation:___________________________
Address:_____________________________

ADDENDUM TO PROPOSAL (In case Life to be assured is a Minor)

“I understand and agree that the policy shall automatically vest on the Life Assured on the policy anniversary
coinciding with or immediately following the completion of 18 years of age and shall on vesting be deemed to be a
contract between the Corporation and Life to be assured.”

Dated at ____________on the ___________day of ______________20 _________

Signature or Thumb impression of Witness Signature or Thumb impression of the Proposer

Name___________________
Occupation_______________
Address_________________

Proposal Form- LIC’s Index Plus

 Addendum to Proposal Form for Settlement Option to take Death Benefit in Instalments

(To be furnished by the Life to be assured / Policyholder)

Proposal No. / Policy No.

Do you wish to avail Settlement Option to take Death Benefit in Instalments? YES/ NO

If yes, please give the following details:

1. Period for Settlement Option to take Death Benefit in Instalments (maximum 5 years):
2. Mode of Installment payment: Yearly / Half-Yearly / Quarterly / Monthly

Note: The instalment shall be the total number of units as on the date of intimation of death divided by total number of
instalments (i.e. 5, 10, 20 and 60 for yearly, half-yearly, quarterly and monthly instalments in 5 year period
respectively). The number of units arrived at in respect of each instalment will be multiplied by the NAV of the
applicable fund type as on the date of instalment payment. The first payment will be made corresponding to the date
of intimation of death and thereafter based on the mode opted by the policyholder i.e. every month or three months or
six months or annual from the date of intimation of death, as the case may be.

Date (DD/MM/YYYY)

Place :

Signature/ thumb impression of the Life to be assured/Policyholder

Name of Life to be assured/Policyholder

Proposal Form- LIC’s Index Plus