Proposal Form

Plan Details

Plan Name Plan No

LIC’s JEEVAN 736
LABH

Proposal Date * UIN

05-05-2025 512N304V03
Agency Code Supervisor Code Branch Code
02516902 6141 902

Access Id Email Id Mobile No.

2550179172 [email protected] 9870969227
I hereby confirm that the mobile number provided by me, is registered in my own name. By ticking this box, I
hereby authorize Life Insurance Corporation of India to verify the above information and call me back even if I
am registered in the Do not call List of TRAI

* Date of Proposal - Pertains to date when customer verified the proposal. Proposal number is
allotted only after receipt of the full proposal-deposit amount by LIC

Details of plan proposed

Term & PPT Sum Assured Installment Premium GST

25 - 16 ₹ 20,50,000 ₹ 25,036 ₹ 1,127
Total Amount Mode of Payment Date of
₹ 26,163 Quarterly Commencement **
05-05-2025
AB/ADDB Req AB/ADDB Sum Assured
ADDB REQUIRED ₹ 20,50,000
Applicable to Police Personnel if LIC's Accident Benefit Rider / LIC's Accidental Death And Disability
Benefit Rider is opted for :
(i). Whether you are engaged in police duty in any police organization other than Yes No
paramilitary force?
If "Yes", (ii). Whether you wish to avail the AB/AD& DB rider while on police duty? Yes No

** Date of Commencement - This date is tentative Date of Commencement , subject to change

based on date of payment and underwriting.

Personal details of the life to be insured

Name
Shwetali Sharad Godse
Father's Name Mother's Name
SADASHIV S KATKAR MANGAL S KATKAR

Gender
Male Female Third Gender
Martial Status Date of birth ABHA number
Married 15-06-1996

Age (in years) Residential Status

29 Years Resident Indian
Do you wish to avail the physical policy document? Yes No

please give EIA no. (e-Insurance Account) if available

Employer-Employee Scheme/KMI/HUF

Whether proposal is under Employer-Employee

No
Scheme/KMI/HUF ?

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Communication details of the life to be insured

Present Address for communication

Address Line 1 Address Line 2
D O Sadashiv Katkar, Dharmatya Nagar,K 25, Mithbunder Road,
Chendani
Address Line 3 City District
Koliwada, Near Subhash Nagar, Thane, Chendani Thane
Thane, Maharashtra Koliwada
State Country Pin Code
Maharashtra India 400603
Permanent Residential Address
Address Line 1 Address Line 2
D O Sadashiv Katkar, Dharmatya Nagar,K 25, Mithbunder Road,
Chendani

Address Line 3 City District

Koliwada, Near Subhash Nagar, Thane, Chendani Thane
Thane, Maharashtra Koliwada
State Country Pin Code
Maharashtra India 400603

KYC Particulars

Are you an It Assessee Yes No

PAN Proof of Identity Age proof submitted

DPWPK9176P ekyc ekyc

If Registered under GST Yes No

Occupation Details

Present Occupation Exact Nature of Name of the present Length of service

duties employer
Service (Listed Service PRICEWATERHOUSE 8 Years
Companies/Institutions) COOPERS SERVICES 2 Months
LLP
Annual income source of income Education Qualification Purpose of
insurance
Professional
₹ 12,00,000 Employed
(Salary)
Are you employed in the Armed Forces Yes No

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Other Personal Details of the life to be insured

Is your occupation associated with any specific hazard or do you take part in hazardous Yes No
activities or have hobbies that could be dangerous in any way?
Are you Politically Exposed Person (PEP) OR are you a family member or close relative of Yes No
PEP ? (As per RBI guidelines PEPs are the individuals who are or have entrusted with
prominent public functions in a foreign country.)
Have you ever been or are currently being investigated, charge sheeted, prosecuted or Yes No
convicted or having pending charges in respect of any criminal/civil offences in any court
of law in India or abroad ?

Lifestyle Details of the life to be insured

Do you smoke / Yes/No If YES, Quantity If STOPPED, Since

consume or have you consumed and how may months
ever smoked / Duration
consumed the
following

Alcoholic drinks Yes No

Narcotics Yes No

Any other drugs Yes No

Do you smoke/consume Yes No

or have you
smoked/consumed
tobacco in any form (
cigars, cigarettes,
beedis, pan masala etc)
in the past 60 months.
(in sticks /packets/
sachets/gms per day)

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Details of previous policies held / proposals applied of the life to be
insured

a) Is your life now being proposed for another assurance or an application for revival of a Yes No
policy on your life or any other proposal under consideration in any office of Life
Insurance Corporation of India or to any other insurer?
b) Whether proposed simultaneously on the life of spouse and children ? Yes No

Has a proposal ( or an application for revival of a policy) on your life made to 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 Yes No

Have you during the past one year returned any policy of the Corporation as the same was not
acceptable to you?, if yes give policy number. Yes No

I hereby declare that I do not have any existing policies in-force or lapsed policies with LIC.

I hereby declare that I do not have any existing policies in force or lapsed policies with other Insurers.

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Medical details of the life to be insured

Are you suffering from or have you ever suffered or undergone investigation in the past or have
you been advised to undergo investigation or treatment for the following ailments
1. Lungs/ Respiratory Disease / Persistent cough, asthma, bronchitis, pneumonia, Yes No
Tuberculosis/, pleurisy / spitting of blood/Covid 19etc
2. Peptic ulcer/colitis, jaundice,Hepatitis, anaemia, piles, dysentery, or any other disease Yes No
of the stomach, liver, spleen, gall bladder or pancreas/ digestive disorder
3.Hypertension, Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, Yes No
any disease of the heart or arteries?
4. Endocrine disorders such as Diabetes, Goitre, Thyroid etc or have you ever passed Yes No
sugar, albumin, pus or blood in urine
5. Any disease of kidney /prostate or urinary system? Yes No

6. Bone / Joint/ Spine Disease/ Arthritis / varicose veins /any bodily defect or deformity Yes No

7. Any disease of ear, nose, throat or eyes, including defective sight or hearing and Yes No
discharge from the ears
8. Cancer/leukemia/lymphoma/ tumour / cyst/ Any other growth / lumps/ blood disorder Yes No
/enlarged glands
9.Paralysis/epilepsy/ insanity/ tremors, numbness, double vision, dizzy or fainting spells/ Yes No
head Injury / insomnia/ nervous breakdown / Mental Disorder (Depression/ Anxiety, etc.).
/ any other disease of the brain or the nervous system
10. Chronic infections- Skin Disease/ skin eruption/ Leprosy / ,filariasis, gonorrhoea, Yes No
syphilis or any other venereal disease or AIDS&HIV related condition
11. Hernia/hydrocele, varicocele, fistula Yes No

12. Any other disease ? Yes No

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Medical History of the life to be insured

Please state exact height and weight ( without shoes)

Height (in cms) Weight (in Kgs)
155 60

During the last five years did you consult a Medical Practitioner for any Yes No
ailment requiring treatment for more than a week ?
Have you ever been admitted to any hospital or nursing home for general Yes No
check up, observation, treatment or operation?
Have you remained absent from place of work on grounds of health during the Yes No
last 5 years ?

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 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)

Relationship Living/Dead Present age State of Age of Death Cause of

Health Death

Father Living 62 Good NA NA

Mother Living 51 Good NA NA

Spouse Living 33 Good NA NA

Sister Living 34 Good NA NA

Daughter Living 1 Good NA NA

Female Life (if applicable)

Are you pregnant now? Yes No

Have you had any delivery history? Yes No

Have you had any abortion or miscarriage or Cesarean section? Yes No

Have you ever consulted a gynecologist or undergone any investigation, treatment for Yes No
any gynaec ailment?
Husband’s details
Husband Full Name Occupation Annual Income
SHARAD GODSE SERVICE 1200000

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Bank details of the life to be insured

Your bank account type Savings Current

Account Number IFSC Code Bank Name

50100219292432 HDFC0001085 HDFC BANK

Settlement Option

Do you Wish to avail Option for Maturity Benefit in installments Yes No

Do you Wish to avail Option for Death Benefit in installments Yes No

Nomination Details

Particulars of Nomination

SI No. name of the Nominee Age Relationship Address of

to the life Nominee Share(%)
assured

1 SHARAD GODSE 33 Husband D O Sadashiv 50

Katkar,
Dharmatya,Nagar,K
25, Mithbunder
Road,
Chendani,Chendani
Koliwada,Chendani
Koliwada, 400603
2 MANGAL S KATKAR 51 Mother D O Sadashiv 50
Katkar,
Dharmatya,Nagar,K
25, Mithbunder
Road,
Chendani,Chendani
Koliwada,Chendani
Koliwada, 400603

Mobile Email Bank Name Account No

Number IFSC Code

HDFC BANK 50100219292432 HDFC0001085

9870969227 [email protected] HDFC BANK 50100219292432 HDFC0001085

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Summary of Section 45 of Insurance Laws (Amendment) Act 2015

(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.
(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
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 sommencement 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:
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.

Summary of Section 41 of Insurance Laws (Amendment) Act 2015

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 other 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 prospectuses or tables of the insurer.
Signature of the life to be
Assured
✔Verified through OTP
By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Declaration of the life to be insured

I Shwetali Sharad Godse 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 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 , financial etc. on the grounds ofprivacy, 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. 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 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 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 respectively 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 above 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 also understand that the
premium and benefits under the policy are subject to taxes / duties/ charges in accordance with the laws as
applicable from time to time.
Signature of the Life
to be insured
✔Verified through OTP
By : Shwetali Sharad Godse
Date and time : 05-05-2025
13:31:41

Name Address Pin Code

Shwetali Sharad D O Sadashiv Katkar, Dharmatya 400603
Godse Nagar,K 25, Mithbunder Road, Chendani
Thane Maharashtra

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
 Suitability Analysis

Proposer Full Name Date of Birth

Shwetali Sharad Godse 15-06-1996

Age Maritial Status Occupation

29 Years Married Service (Listed Companies/Institutions)

Address
D O Sadashiv Katkar, Dharmatya Nagar,K 25, Mithbunder Road, Chendani Chendani
Koliwada 400603

2. What is proposer'yearly income from: (if life assured is different from the proposer)
Employment Businees / Profession Other Sources H.U.F. if any

Income of life to be
assured

3. Whether income proof submitted? (if Yes, give details below)

Nature of document Is he/she Income tax Is yes, please provide Income Tax Bracket
for income verification Assessee PAN
Yes DPWPK9176P

4. Previous Policy Details (as per proposal form)

5. Family History (as per proposal form)
Spouse Details
Name Occupation Annual Income
NA NA NA

6. Need Analysis
Total Annual Income
₹ 12,00,000

Outstanding Liablities
Secured Loans Non-Secured Loans

based on his age and income, the maximum insurance that can be granted is:
Age Group Multiple of Avg. Maximum allowable
Annual Income Insurance

7.
Object of Insurance How would you like to pay your premiums
Quarterly
Risk Profile Time frame for this invesement

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
8. Categorization of plans in relation to object of Insurance
Category Risk Profile Plan Name
LIC’s JEEVAN LABH

9. Product Chosen
Plan No Plan Name Term Sum Assured
736 LIC’s JEEVAN 25 ₹
LABH 20,50,000
Mode Premium
Quarterly ₹ 25,036

a) if ULIP is proposed:
1st Year 2nd Year 3rd Year onwards Life cover
charges

Policy Administration Fund Management

Charges Charges

b) if Annuity / Pension is proposed:

Target Annuity per annum Type of Annuity Annuity Amount per Defement
annum Period

Is the total insurance added to the present proposal is reasonable in relation to income
The questions above pertain to your personal condition at the time of appliction to your understanding of the
features of the product for which you are applying. This information will not be used for any other purpose and
will remain confidential.
I Shwetali Sharad Godse, having received the informationwith respect to the above, have understood the
selection of product befor into this contract. My plan details are as following:
Plan No Plan Name Term Sum Assured
736 LIC’s JEEVAN 25 ₹
LABH 20,50,000

Mode Premium
Quarterly ₹ 26,163

KYC Details as per E-KYC

Personal Details
Pan No
DPWPK9176P

Name Date of Birth

Shwetali Sharad Godse 15-06-1996

Gender
Female
Contact Details
C/o. House/ Bldg. / Apt.

Steert/ Road/ Lane Landmark

D/O: Sadashiv Katkar, Dharmatya Nagar,K/25, Mithbunder Road,
Chendani

Area/ Locality/ Sector Pincode

400603

Village/ Town/ City P.O.

Chendani Koliwada

District State
Thane Maharashtra
 CUSTOMER INFORMATION SHEET /KNOW YOUR POLICY

This document provides key information about your policy. You are also advised to go through your
Policy Document.

Name of the Insurance Product And Unique Identification Number (UIN)

LIC’s JEEVAN LABH (UIN: 512N304V03) Part A

Policy Number
Part A

Type of Insurance Policy

Non-Linked other than Pure risk and pension Part B - Definitions

Basic Policy details

Instalment Premium (Rs): ₹ 25,036 (Taxes, if any, as applicable from time to Schedule
time are charged extra).
Mode of Premium Payment: Quarterly Schedule
Premium Payment Term: 16 Schedule
Policy Term: 25 Schedule
Basic Sum Assured (Rs): ₹ 20,50,000 Schedule
Sum Assured on Death: Sum Assured on Death is defined as Higher of Basic Condition 1.A of Part C
Sum Assured or 7 times of Annualized Premium
Sum Assured on Maturity: Sum Assured on Maturity is equal to Basic Sum Condition 1.B of Part C
Assured.

Riders opted, if any

Not Applicable (if rider is not opted) Rider Name and UIN (as opted for by the Schedule
policyholder) For details of Benefits and Conditions of riders(s), mentioned above,
refer Endorsement to this policy.

Policy Coverage / benefits payable

Benefit payable on Death: Death benefit payable in case of death of the Life Condition 1.A of Part C
Assured before the stipulated Date of Maturity provided the policy is in​force shall
be “Sum Assured on Death” along with vested Simple Reversionary Bonuses and
Final Additional Bonus, if any.

This Death Benefit shall not be less than 105% of total premiums paid upto the
date of death.
Benefit payable on Maturity: On Life Assured surviving the stipulated Date of Condition 1.B of Part C
Maturity provided the policy is in-force, “Sum Assured on Maturity” along with
vested Simple Reversionary Bonuses and Final Additional Bonus, if any, shall be
payable. any.
Surrender Benefit: The policy can be surrendered by the policyholder after Condition 4 of Part D
completion of first policy year provided one full year’s premium(s) has been paid.
However, the policy shall acquire Guaranteed Surrender Value on payment of
atleast two full years’ premiums and Special Surrender Value after completion of
first policy year provided one full year’s premium(s) has been paid. On surrender of
an in-force or paid-up policy, the Corporation shall pay the Surrender Value equal
to higher of Guaranteed Surrender Value and Special Surrender Value
Options to Policyholders for availing benefits, if any, covered under the
policy: Condition 8 of Part D

i) Option to take Death Benefit in instalments: This is an option to receive

Death Benefit in instalments over the chosen period of 5 or 10 or 15
years instead of lump sum amount under an in-force as well as paid-up
policy.
ii) Settlement Option (for Maturity Benefit): Settlement Option is an Condition 8 of Part D
option to receive Maturity Benefit in instalments over the chosen period
of 5 or 10 or 15 years instead of lumpsum amount under an in-force as
well as paid-up policy.

Options available (in case of Linked Insurance Products)

Not Applicable

Option available (in case of Annuity product)

Not Applicable

Exclusions (events where insurance coverage is not payable), if any.

Suicide Exclusion: The provisions related to claim payment in case of death due Condition 2 of Part Fx
to suicide shall be subject to the conditions as specified herein under:

i) If the Life Assured (whether sane or insane) commits suicide at any time within
12 months from the date of commencement of risk, the Nominee or Beneficiary of
the Life Assured shall be entitled to 80% of the total premiums paid till the date of
death (excluding any extra premium, rider premiums other than term assurance
rider, if any and taxes, if collected explicitly), provided the policy is in force.

ii) If the Life Assured (whether sane or insane) commits suicide within 12 months
from date of revival, an amount which is higher of 80% of the total premiums paid
till the date of death (excluding any taxes if collected explicitly, extra premium and
rider premiums other than term assurance rider, if any,) or the surrender value
available as on the date of death, shall be payable. The Nominee or Beneficiary of
the Life assured shall not be entitled to any other claim under this policy.

Waiting/ lien Period, if any

Not Applicable

Grace period

30 Days for Yearly, Half-yearly, Quarterly mode of premium payment Condition 6 of Part C
15 Days for Monthly mode of premium payment

Free Look Period

30 Days Condition 7 of Part D
Lapse, paid-up and revival of the Policy

Lapse: Lapse is the status of the policy when due premium is not paid Part B-Definitions
within the days of grace.
Paid-Up: If after at least one full year’s premium(s) has been paid and condition 2 of Part D
any subsequent premiums be not duly paid, on completion of first policy
year, this policy shall not be wholly void, but shall subsist as a paid-up
policy till the end of the policy term.
Revival: A policy in lapsed condition may be revived during the life time Condition 3 of Part D
of the Life Assured, but within the Revival Period and before the date of
maturity, as the case may be.

Policy Loan, if applicable

Loan can be availed after completion of first policy year, provided one full year’s Condition 5 of Part D
premium(s) has been paid and shall be subject to the terms and conditions of the
policy

Claims/ Claims Procedure

 Turn Around Time (TAT) for claims settlement and brief procedure: Condition 4 of Part F

S Bench
Description of Service
No Marks
1 Maturity claim/Survival Benefit/Annuity/Pension On or
processing subject to receipt of all documents before due
date
2 Raising claim requirements after lodging the claim 15 days
3 Death Claim Payment/Rejection/Repudiation without 30 days
investigation requirement under a Life Policy
4 Death Claim Payment/Rejection/Repudiation with 120 days
investigation requirement under a Life Policy

Helpline/Call Centre number: 91-022-68276827 SMS LICHELP TO

9222492224 Whatsapp No.: 8976862090

Contact details of the insurer: You may contact us at our Branch

Office the details of which are mentioned in the Part A (First page) of the
Policy Document. Alternatively the Branch Locator can be found on the
below link: https://licindia.in/branch

Link for downloading claim form and list of documents required

including bank account details: https://licindia.in/web/guest/download-
forms
List of documents required:

1. Claim forms, as prescribed by the Corporation

2. Policy Document

3. NEFT mandate

4. Proof of title

5. Proof of death

6. Medical treatment prior to the death (if any)

7. school/college/employer’s certificate, whichever is applicable

8. Proof of age of the Life Assured, if the age is not admitted under the
policy, shall also be submitted

9. First Information Report (FIR), Panchnama and Post Mortem report

where applicable

10. Any other additional documents as may be required by the

Corporation
For updated details, we request you to regularly check our website www.licindia.in

Policy Servicing
 Turn Around Time (TAT):

S
Description of Service Bench Marks
No
1 Free look cancellation/ surrender/ Withdrawal/ 15 days
Request for refund of proposal deposit/Refund of
outstanding proposal deposit subject to receipt of
all documents
2 Raising claim requirements after lodging the claim 15 days
3 Issuance of policy document after acceptance of 5 days
the proposal
4 Registration of nomination/ Assignment/ Re- 3 days
assignment and return of policy document
5 Effecting revival/ alteration/ issue of duplicate 2 days
policy on receipt of all requirements
6 Loan Settlement after receipt of all requirements 3 days
7 Intimation of status of SSS policies Once a year
along with
Bonus
informa tion

8 Effecting change of address/ transfer In-Out and Same day

other enquiries under the policies
9 Acknowledge a grievance 3 days
10 Resolve a grievance 15 days

Helpline/Call Centre number: 91-022-68276827 SMS LICHELP TO

9222492224 Whatsapp No.: 8976862090

Contact details of the insurer: You may contact us at our Branch

Office the details of which are mentioned in the Part A (First page) of the
Policy Document.

Alternatively the Branch Locator can be found on the below link:

https://licindia.in/branch

Link for downloading applicable forms and list of documents required

including bank account details: https://licindia.in/web/guest/download-
forms

For updated details, we request you to regularly check our website

www.licindia.in

Grievances /Complaints
Contact details of Grievance Redressal Officer of the insurer:
You may contact the Grievance Redressal Officer on the address as
mentioned in the Part A (First page) of the Policy Document.

Alternatively the details of Grievance Redressal Officers can be found on

the below link: https://licindia.in/web/guest/grievances
Link for registering the grievance with the insurer’s portal: If you
are a registered policy holder you can directly register complaint/
grievance and track its status through our Customer Portal (website)
http://www.licindia.in. You can also contact at e-mail id
[email protected] for redressal of any grievances.

Link for registering: https://ebiz.licindia.in/D2CPM/?_ga=2.7

2703123.1272923387.1677050657- 120722208.1677050657#Login
Contact details of Ombudsman: You can also approach Insurance
Ombudsman whose Address and contact details is given in Part A (First
page) of the Policy Document.

Alternatively the details of Ombudsman can be found on the below link:

https://cioins.co.in

Contact No. 022-69038800/69038812

Declaration by the Policyholder

I have read the above and confirm having noted the details.

Place:(Signature of the Policyholder)

✔Verified through OTP

By : Shwetali Sharad Godse
Date and time : 05-05-2025 13:31:41
Note:

i. Product related documents including the Customer Information sheet are available on
Corporation’s website www.licindia.in

ii.In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
 LIC's Jeevan Labh (Plan No. 736)

Benefit Illustration

LIC's Jeevan Labh (Plan No. 736)

A Par, Non-Linked, Life, Individual Savings Plan
(Unique Identification Number - 512N304V03)

RAVINDRASING
Distribution channel Offline Agency name Agency code 02516902
BALUSING PAWAR
Name of SHWETALI SHARAD Age of 28 years Date of illustration 05-05-2025
prospect/policyholder GODSE prospect/policyholder
SHWETALI SHARAD
Name of life assured Age of life assured 29 years Benefit UID/Proposal no.
GODSE
Mode of payment of
Policy term 25 years Premium payment term 16 years Quarterly
premium
Sum assured on death Instalment premium
Basic sum assured Rs. 20,50,000 20,50,000 24,369.00
(at inception of the policy) Rs. (for base plan)

Bonus type Simple reversionary and final additional bonus

How to read and understand this benefit illustration?

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy, at two assumed rates of interest i.e., 8% p.a. and 4% p.a.

Some benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance business. If your policy
offers guaranteed benefits then these will be clearly marked 'guaranteed' in the illustration table on this page. If your policy offers variable benefits then the illustrations on this
page will show two different rates of assumed future investment returns, of 8% p.a. and 4% p.a. These assumed rates of return are not guaranteed and they are not the upper
or lower limits of what you might get back, as the value of your policy is dependent on a number of factors including future investment performance.

Premium summary
Particular Base plan Riders1 Total instalment premium
Instalment premium without GST 24,369.00 667.00 25,036.00
Instalment premium with GST @ 4.50% (1st year) 25,466.00 697.00 26,163.00
Instalment premium with GST @ 2.25% (2nd year onwards) 24,917.30 682.01 25,599.31
GST rate shall be as applicable from time to time.

Page 1
 LIC's Jeevan Labh (Plan No. 736)

(Amount in rupees)
Total benefits (including guaranteed and non-
guaranteed benefits)
Guaranteed benefits Non-guaranteed benefits @ 4% p.a. Non-guaranteed benefits @ 8% p.a.
Maturity benefit Death benefit4
Annualize Maturity Death
Policy Maturity Death
d benefit, benefit,
year (End premium benefit, benefit,
2 incl. of incl. of
of the Total Total incl. of incl. of
(cumulativ Guarantee guarantee Special guarantee Special final final final final
year) d Death Maturity Reversion Surrender Reversion Surrender additional additional additional additional
e) d surrender d surrender
surrender benefit benefit ary bonus surrender benefit ary bonus surrender benefit bonus bonus
value3 value3 bonus bonus
value (FAB), if (FAB), if
value3 value3 (FAB), if any, (FAB), if
@ 8% any, @ 4% any, @ 8%
any, @ 4%
(5+6+FAB) (5+10+FA (4+6+FAB) (4+10+FA
B) B)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

1 95384 0 2050000 0 8200 0 23857 23857 61500 0 23857 23857 0 0 2058200 2111500

2 190768 58486 2050000 0 16400 58486 51096 58486 123000 58486 51096 58486 0 0 2066400 2173000

3 286152 102350 2050000 0 24600 106109 87316 106109 184500 130542 121455 130542 0 0 2074600 2234500

4 381536 194952 2050000 0 32800 200010 124710 200010 246000 232885 173469 232885 0 0 2082800 2296000

5 476920 243690 2050000 0 41000 250066 167066 250066 307500 291506 232385 291506 0 0 2091000 2357500

6 572304 292428 2050000 0 49200 300162 214794 300162 369000 350435 298773 350435 0 0 2099200 2419000

7 667688 341166 2050000 0 57400 350310 268342 350310 430500 409745 373258 409745 0 0 2107400 2480500

8 763072 403941 2050000 0 65600 414581 328707 414581 492000 483743 457224 483743 0 0 2115600 2542000

9 858456 469347 2050000 0 73800 481583 396297 481583 553500 561117 551240 561117 0 0 2123800 2603500

10 953840 539042 2050000 0 82000 553007 471821 553007 615000 643777 656292 656292 0 0 2132000 2665000

11 1049224 612247 2050000 0 90200 628104 556342 628104 676500 731176 773860 773860 0 0 2140200 2726500

12 1144608 687791 2050000 0 98400 705090 650434 705090 738000 817531 904739 904739 0 0 2148400 2788000

13 1239992 767916 2050000 0 106600 786742 755145 786742 799500 909108 1050390 1050390 0 0 2156600 2849500

14 1335376 851550 2050000 0 114800 872042 871826 872042 861000 1005239 1212690 1212690 0 0 2164800 2911000

15 1430760 937232 2050000 0 123000 959569 1001375 1001375 922500 1104758 1392890 1392890 0 0 2173000 2982750

16 1526144 1027787 2050000 0 131200 1052190 1145348 1145348 984000 1210811 1593153 1593153 0 0 2181200 3044250

17 1526144 1054300 2050000 0 139400 1081037 1232851 1232851 1045500 1254827 1743076 1743076 0 0 2189400 3116000

18 1526144 1082374 2050000 0 147600 1111791 1327350 1327350 1107000 1302999 1906828 1906828 0 0 2197600 3187750

19 1526144 1110447 2050000 0 155800 1142931 1429358 1429358 1168500 1354079 2085588 2085588 0 0 2205800 3259500

20 1526144 1136960 2050000 0 164000 1173024 1540058 1540058 1230000 1407437 2281568 2281568 0 0 2214000 3331250

Page 2
 LIC's Jeevan Labh (Plan No. 736)

(Amount in rupees)
Total benefits (including guaranteed and non-
guaranteed benefits)
Guaranteed benefits Non-guaranteed benefits @ 4% p.a. Non-guaranteed benefits @ 8% p.a.
Maturity benefit Death benefit4
Annualize Maturity Death
Policy Maturity Death
d benefit, benefit,
year (End premium benefit, benefit,
2 incl. of incl. of
of the Total Total incl. of incl. of
(cumulativ Guarantee guarantee Special guarantee Special final final final final
year) d Death Maturity Reversion Surrender Reversion Surrender additional additional additional additional
e) d surrender d surrender
surrender benefit benefit ary bonus surrender benefit ary bonus surrender benefit bonus bonus
value3 value3 bonus bonus
value (FAB), if (FAB), if
value3 value3 (FAB), if any, (FAB), if
@ 8% any, @ 4% any, @ 8%
any, @ 4%
(5+6+FAB) (5+10+FA (4+6+FAB) (4+10+FA
B) B)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

21 1526144 1165033 2050000 0 172200 1205293 1659983 1659983 1291500 1466986 2496101 2496101 0 0 2222200 3403000

22 1526144 1193106 2050000 0 180400 1238296 1790119 1790119 1353000 1532033 2731248 2731248 0 0 2230400 3495250

23 1526144 1219620 2050000 0 188600 1270655 1931912 1931912 1414500 1602384 2989864 2989864 0 0 2238600 3587500

24 1526144 1403654 2050000 0 196800 1462694 2086378 2086378 1476000 1846454 3274244 3274244 0 0 2246800 3679750

25 1526144 1403654 2050000 2050000 205000 1475404 2255000 2255000 1537500 1941779 3792500 3792500 2255000 3792500 2255000 3792500

Notes:

The main objective of the illustration is that the client is able to appreciate the features of the products and the flow of the benefit in different circumstances with some level of
quantification.
This illustration is applicable to a standard (from medical, life style and occupation point of view) life.

1. It includes rider(s) premiums in respect of all the rider(s) opted by the proposer/policyholder at inception of the policy.
2. Annualized premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any, and goods & service tax. Refer
sales literature for explanation of terms used in this illustration.
3. Surrender value is higher of guaranteed surrender value (GSV) and special surrender value (SSV). SSV shall be reviewed in line with IRDAI Master Circular on Life
Insurance Products (Ref no.: IRDAI/ACTL/MSTCIR/MISC/89/6/2024 dated 12th June, 2024) and any subsequent circulars issued by IRDAI in this regard. For surrender
value calculation, it is assumed that the bonuses shall vest upon its declaration based on experience of the Corporation under this product, in the manner as per the terms
and conditions of annual valuation results.
4. In any case, the total death benefit during the policy term shall not be less than 105% of the total premiums paid (excluding GST, extra premium and rider premiums, if
any).
5. The actual allocation to policyholders, out of the surplus emerging from the actuarial investigation, shall be in accordance with provisions in this regard under LIC Act, 1956.

Page 3
 LIC's Jeevan Labh (Plan No. 736)

I, ________________________________________ (name), having received

I, ________________________________________ (name), have explained the information with respect to the above, have understood the above statement
the premiums and benefits under the product fully to the prospect/policyholder. before entering into the contract.
Place :
Place :
Date : Signature of agent/intermediary/official of the insurer Date : Signature of prospect/policyholder

Page 4
 Payslip For : MAR-2025
PricewaterhouseCoopers Services LLP
Amount in INR

Employee Code 101367151 Employee Name Shwetali Katkar

Date of Joining 16/01/2023 Bank Name HDFC
Account No 50100219292432 PF No. GNGGN19505400000025301
PF UAN 101231945250 PAN DPWPK9176P
EPS No GNGGN19505400000025301 Location MUMBAI
LOP Days 0 Work Days 31
Designation Senior Associate

EARNINGS EARNED DEDUCTIONS AMOUNT

BASIC 40,633.00 PROVIDENT FUND 4,876.00
HRA 20,317.00 PROFESSION TAX 200.00
SPECIAL ALLOWANCE 35,757.00
GROSS EARNINGS 96,707.00 GROSS DEDUCTIONS 5,076.00
NET PAY 91,631.00

Remarks :

** This is a computer generated payslip and does not require signature and stamp.
 Payslip For : MAR-2025
PricewaterhouseCoopers Services LLP
Amount in INR

Employee Code 101367151 Employee Name Shwetali Katkar

Date of Joining 16/01/2023 Bank Name HDFC
Account No 50100219292432 PF No. GNGGN19505400000025301
PF UAN 101231945250 PAN DPWPK9176P
EPS No GNGGN19505400000025301 Location MUMBAI
LOP Days 0 Work Days 31
Designation Senior Associate

EARNINGS EARNED DEDUCTIONS AMOUNT

BASIC 40,633.00 PROVIDENT FUND 4,876.00
HRA 20,317.00 PROFESSION TAX 200.00
SPECIAL ALLOWANCE 35,757.00
GROSS EARNINGS 96,707.00 GROSS DEDUCTIONS 5,076.00
NET PAY 91,631.00

Remarks :

** This is a computer generated payslip and does not require signature and stamp.
 Payslip For : MAR-2025
PricewaterhouseCoopers Services LLP
Amount in INR

Employee Code 101367151 Employee Name Shwetali Katkar

Date of Joining 16/01/2023 Bank Name HDFC
Account No 50100219292432 PF No. GNGGN19505400000025301
PF UAN 101231945250 PAN DPWPK9176P
EPS No GNGGN19505400000025301 Location MUMBAI
LOP Days 0 Work Days 31
Designation Senior Associate

EARNINGS EARNED DEDUCTIONS AMOUNT

BASIC 40,633.00 PROVIDENT FUND 4,876.00
HRA 20,317.00 PROFESSION TAX 200.00
SPECIAL ALLOWANCE 35,757.00
GROSS EARNINGS 96,707.00 GROSS DEDUCTIONS 5,076.00
NET PAY 91,631.00

Remarks :

** This is a computer generated payslip and does not require signature and stamp.