@mffi--m.m-ffi(#fi +qI Rrrq slfBft{q 1956 am dlelrFal

(Established by the Life lnsurance Corporation Act, 1956)

Er{Iqqra orqftprq:Divisional Otfice

uM/g.d.S.q. or ilqAgent's/CLIA's Name :

dr{S-s i.Licence No. :

1on "*

*= t*l *gl I vt$r wef lt ti qGt I tsr, Rg w erq frilft ro'n S fr< strq s sq d T&6R TS fu-n srs'i I

(All Answers to be filled in legibly, Answers must be given in words, stroke of the pen or dots or dashes will not be accepted as replies')

I5,rd d'.300/F. No. 300 (Rev. 2002)

twdqE ftqr Kilil rt:l PRoPosALFoR lNsuRANcEoNowN LIFE

(qqqffi d ffd d frq TSfr Wftr 1 "i7*ot

to be used lor Insurance on the Lives of minors)

lnward NumberSTrir6'Ti.

DateRqiu

Frqfdq Office use :

wan rqio Proposal No. :

qql vlfu Amt. of Deposit :

ff.d.iff. d. s.o.c. t'to. :

Rqr6

To be filled in bY the

1 .

otrulFFuJJ

vooJo

=

2A

ftt or sivqObject of Insurance

q"t arr (€il{rq cQIq) qq trfl ftrsil ttalEnq fu'qt qr}rn I(-iull Name (Sumame first) and Address to which communication are to be sent.

uftqf, ifirg nqu In ot frawtNature of Age'Proof submitted

vs.d.d. atcS.T.D. CODE

q3. : ErTel.: Res.fr{rs trcr (errn sFafuc * oraq d

{-ta E-mail:

l) Residential address, if different from above. qq RID/Date of Birthotq 1ft-q.trt E{qi-6 rrt)

ftsr or TqT crq (ga-{rq geFl)/p616sr's Full Name (Surname first)rif*q -Trq

Short Name

onq qi Tr€r.tlRelationship to yourself

*na qfu oT Wr arr (grtrr cerq) Ti trfrl

Nominee's Full Name (Surname first) and Address

rr6qh d rssc ri frgffi qfrf, d E€IenSignature of Appointee as token of consent

Gnfr qrfu qRq er+rr+'t, d ftTfi qtih o't {u qrlt F tltll

lf Nominee is a Minor, Appointee's Full Name and Address

fuioqRqfufl6tcnotffift0tq'rttt

lf policy is to be datedback indicate date

w $em Rrontdsrqv{oil tt

ls Accident

.frlr tFI KIRa ftqt rc(oRelwo{1

Critical illinessSumProposed (lf reqd.)

frqr dnlqr qq iisBPlan & Term

to eprfl i. m.Badge or S. Fl. No.

5.rdrq crfBo.rt 6tsPaying AuthoritY Code

g,rdrn frfd (qrNo, u:rmff, ffi, qIRr6qr i. q. d.)/Mode (YearlY, Half YlY.,Quarterly, Monthly or under SSS)

6rd d qrfrfto gqft/Exacl Nature of DutiesTftnq qffrq,/tflI/Present Occupation

srd vnel tl.qr d smfB/t-ength of Service with himFfqrq ffiml q1 rTrq/Name of present employer

IFII sllq slfqcF-t SfaT t ?

Are you an lncome Tax Assessee?sTrq d Tflff{

Source of lncome

qlff-6 slrq rF.Annual Income Rs

@+o*q r t *dqq4 f t l qo rsdqo i | : f f youa reemp |oyed in theArmedForces ,p |eases ta te .@r oTrs 6'S M q-1 * dl-i srs .n

r* * qR si d 6qllWere you ever below A-1 category? lf so, when?

smq cffqrdqrq er*q EtoftMedicalcategory aftermedical examination

ftrn *qne{ cffffI d frftDate of last MedicalExamination

inr+ @} frs*urqsqRdtWing to which you belong

wr frrc + fuff *,rqf6q rrr cr{r st{ ftcFrdf st oTs sTrrd *fi ftt or "i{

*ffi;-ff,ff"m^9-"ry.t sfn 4t{ cIQt* rn q\r{ filrqrrqr t? er.rg df d turwr t rls vour life now being proposed for another assurance or an appiica,i". ilr il'"i, J. i"ll., Lffi;;'life or any other proposal under consideration in any otfice oi n" corporation or to any other insurer ?lf "yes'give details.

rn irq o,H *qrodf qi tr€aE.rqtsrrrd *{q *i or ot{ rsre q, (qr ffird #fi +qr-fiffi dg-+{cc * r+q,p* e+{ cpftll y{) e.'ftHas a proposal (or an application for revival of a policy) on your lifemade to any office of the corporation or to any other insurer ever been(ol) qrvs e fuqr, wil<t, lerFto ql

"rrftEe or Rqr rrqr t?

(a) Withdrawn, Deferred, Dropped or DeclineJ?(q) eftfu *n gm rn rT6q d nnr rftq-d eiql q.ql ff(b)Accepted with Ex'ira premium or t_ieni

' " '"

(tr) c-Rrfu rrd d srfrRfi cm vrd w *q-a fuqr rrqr t?(c) Accepted on terms otherwise than those

giirq "c1,, ?nrrqiflrr { *FrEAnswer "Ygsoor "Non

qR sil{ 'd'{ a} qvrF-srq dfunlf Yes, give details

Ril sTrqi frg-a qE'q{ { Aqq ft1 6t$ gtfuff Erfu{ ffi Ftffr T6 3TFr6} ra6nHave you during past one. yea.r retumed any policy of the corporation as the same was notacceptable to you? lf so give details

'rs cffr qR 6i d ft4qq g 1

uffi *11 M clfrfuf iFl fiA f{rqe:(inc|udingPoliciesSurrendered/Lapsedduring|ast3years)

qfrcfldqfuq grdrArwoltq

hftqrsrqqof hfu

l f no t , g i vedue date of

las i premiumpaid or date

{lfrRft dqrPolicy Number

{qoq{doqn$icf,tqri*clfr{flqlqftfsrfi

il.Iit (qfrqffinf{0nd'r{ddvrqr/q.o. or

Tq{)lnsrameCcrnfarbsfromwhaetrcprevirrsphy/

@ftieshaebeenS.rdtasedwihaddess(lfprar.pdbbsarelranLlC

of Ind[a, gire rwned

qlffi

ffi'frqmfls|fr

qrqrqr{iw lflqazWhether

accepted asproposed

at ordinaryrates, if not,give details

Fgq : qR M flq qd dirqr frt{ $rS {ffi

;r;;il;,;t** up Poticy within rhe lasr 3 yeas.qtffio Efrga Famity History

lqrFq d furh/State of Heatthat the time of death Tq 6'I onut/Cause of death

rn{ r/ Brother(.) ffi rio alive Noj

#fc d" Alive No.q-€ /Children

1 1 . ffi6 Efrge/ Personal History wqdqrSif {tuqAns'rprYes'or No

fi GR Er { d qqr F-flgl Afrqlf 'Yes' Please give full details

(o) wl slrqi M ciq rrsl d +d{ ffi tS *qrQct qrqvqo-fl vO Gl, ArS frfu.mr * Tgr.Rf fuql t?

(a) During the last five years did you consult a Medical Practitioner for any ailment requiringtreatment for more than a week?

(q f,i rFFr ul 6.ff qiq +{rqrd, g.ntrg qr fits rm d vrq frfur d Flghffi q{rdra qr*cr-Ta it <frra fr-qr rql tl

(b) Have you ever been admitted to any hospital or nursing horne for general check-up, observation,treatmsnl or operation?

(.I)

(c)

qqr qFr REd qi" ilI + drtrl Fmpq t vrsrr rr{ qqi 6Td i aqqRril rt t?Have you remained absent from'ptace of work on grounds of heatih during the last s years?

(e) inlr smt fu.R, +c, F{q, N, gcl qff,n'cr rni ergr-ca dqfu ffi fi * qrtff qBitvttETn vrq frFd t?

(d) lAre you suflering from or have you ever suffered from ailrnents partaining to Liver, Stomach,Heart, Lungs, Kidney, Brain or Nervous system?

(9 mr irFr €*r. rq, gE ltt fu $Fr qIlI, crq{, M, sit| gtrql, cH Tl rffl, llT s.i hffic-q *q i Of_d d t qr Tf, grrq AFd t?

(e) Are you sutlering from or have you ever suffered from Diabetes, Tuberculosis, High-Eood Pressure, Low Blood Pressure, cancer, epilepsy, Hemia, Hydrocele, Leprosy or any other disease?

(s)(f)

qt orqqi nrofu rqr.r€ { sil TA qr s}c t?Did you have any bodily defecl or delormity?

(s)(s)

rrrll sFr ro'0 gf{rrs En t qr silqqn *s ir.fl t?Did you ever have any accident or injury?

(q) iFrI 3rFr ffifud or *ac o-ti t qr 6'fr fuqr t? l lny Do you use or have you ever used?

(i) lrrTV Alcoholic drinks

(ii) qrqsr Fq / Narcotics

(iii) ot{ lr;q qrFd fil / Any other drug

(iv) aqrq fulft S sq d/ Tobacco in any form

il

iDiii\

iv)(c)(i)

TFrirft firq! snra qff Rfit +d yfl t?What has been your usual state of health?

(q) qst srqd qt{ rp vilu (iqeqzSw {) ql f'gs g qrqfur hfrr.ril ciq, vdrE s1rril swrr stqftu t lrlril rrfqn d cmr rr{ ri tZrrrr vt tr

0) Have you ever received or at present availing /undergning medicat advicq tr€atmefi or tests inconn€ction with Hepatitis B or AIDS related conditon?

fn RFff qrmit { Errqr rrfl dqrC +A+cr il vi qtla fuci { frrdr (fua qi)In Non-Medicalcases, please state exact Height in Cms. and Weight in Kgs. (Without shoes)

dqr{Height

IIGFI

Weight

d ffqFff d frq FoRFEMALEpRopoT{ENT

iFrr qFr.nfcfr t rAre you Pregnant now?

tud mrs d frE fttuqDate of Last Delivery

Fn snc6l off q{crir lt q{etq qr fudftqn EEr qr?fi Eii} ftflq {frrlave yw had arry abotion o miscani4e aceasarian section? lf So, gve detailr

Rud qrtuo, qd d hft fttuqrDate of Last Menstruation

qft ot qw rra/Husband's FultName (frifl a|?ff,fqft{is Occupation vrrd qll+o, qFVHis Annualtncome

ch d *t * rrrqfud ftflq/Ds1sils o{ Husband's tnsurance

fiffi d@rPolicy Number

*n s441* w G tm qti *qffi ql qhtudt d'd t(fi tGMr{S * d tr{ d n} nrgl /r.or. or ;nr t) /dlcedilracorponrhn ettltlcc of lln otha Inururf ron rlrscthe pcrbm plb1, potbb hw! btar Fndted

wlth ad&es.'lf pevlouspollctssuclrom UCollndlr, gln Naruof Br./00.

dq qrSum Assured

drfu6r s qsfuTabb&Term

dffi afr rtuq tufrPresent Status of the Policy

irrr 3Trq i silTd acl d qd, qrfr qtq-{ qtisfr ffi si vrdl dr Wf sq fr qq-s frfl t rl'lave you understood fully the terms & conditions of the plan you propose to take?

'ri" T "qr"

Yes i No'sRITq?F arql dqw, DECLARATION BY THE PRoPosER

12.

1 3 4

1 3 8

1 3 C

1 4

{-r---*=-------.rtr{ s.i sfl.lt lr| stct d ro aw rq +++ rlqfrn.d C atti !r iO t an r+i itar"r Et *;i. {i #{'ilH'ibql{-rt tr t\rraEfur"il$srq< t drr qlfts u'rtllztvri {-fr t r+l; dr w e}rm *i d crrfri dirc fqr ery t qe {sr

-*:q st .ri"'*rr ,il'cfi"F{ #i;; ;aqJ1aqrltr ri ttt qft EkArt rafr frv'a t qryqr fll !q qqq'if g.ar1{.q{ sqfi Gqt ii|Iq ani'qrr" ai h ffii'-.'

"-

3:t$r:-"-s,ri:t1-td";*i''til;*?'1"'ffiisff"HJ'#ti:ffi'#Hf*ff:!81;';i&HffiHfiji]i;:ffii'-ffi"tri,!InDrmalon ans I oo nereDy aglee and declar€ thal th€6e slatemonts 8nd lhls declaration shsll be the balls ot the cont'rtct ol a$urance betvre€n me and the tif;:1":gSm11gl19_Ad"tF!19!f ","tte

av€ment b€ conbin€d thoEin the said conract sharr * *dGry nuu irno voio-aioa-tmureyr wrrt*r sharr rnveDeen p6|q In respecN n€rc ol tha stand fodelted to tho corporation,. fud xshn grF. th Rcrq, Taq qr rct i-6Eq ArS Ffrrsr, qglrra dfrZqr iir+q q) qqtr q{ it RR.z ql {hre i sqfud R 0 inr{E|0 cr qs-Jrd-rqe qli w-ffiir ti !c { n fi q-i ffi,. {*Td riq6l, ;RqActq: q,qrfi- qq{ q-{ q'H qfr etd tu{ ;r#'i .t f*'t ,#A';iij#ctGdiniF{ il fiG t, cd{elil irfi ti t ft Qt zqtu qr rir;c Ft?i'qh !i x6tl ii'. ci{ ss-{ i, {cnft--d;'i#'iiq; # S'J{-ffiii';ii;iiRiil rti I

^^,,1:j$gl':9f_tYitlT-"lTlry rq"Se, custorn or conventjon for h€ tirne b€ing in torce ptltribiting any docror, hocp atard /or er$qEf film divutgingarry Knou,Eqge or InomE[on aDout m€ @nceming my health or €mploymont on ths gpundg olsgcr€cy. l, rry hbi6, exgcutor!, idmlnlstratoB td-asslgnoss or-aniolher penx,n or peBons' having interegt ol any kind whatso€vor in he policy contract issr.Fd to me, trereuy agree ttrat such aurhoai, havirlg suchk-nowledge ;hfomation, shall at any time be at lborty to divulgs any sudt knort€dgd or iiloma on to tr}e CoEoration. ' -

- - t r tEcr ln . * f fdEqd( f t rcnHvr i ! iF tR*Tqf t -Ss lc f f fa {cvrmcqr f lE} i i$qE(1) t tq {g lq++{q f f i r r lq rn fq r iQ

"t€f.r .QR Tn"t g $ cR?ii i.ffi qF d qrq * q<tu< ot{ffia qfftuftr €rqr A #a t ?*cr qh idir" rE ihi'ffi; c,iii*;stc-;firi 6 Rq ftrq d ffi-Erqidq sr) Fqd fr'ql rqr lrli fltfi yr q|q{ i ftqr qrei t 4 rq. wftn qr in{t€; F{ Rq qrol t rn cffrfuq Sn ia qrirFr (Li€!l) d qFrr{ Y{ frW fiEl qr t.nr r<tlftt trdl i ra[c|+{|rfu{l fi t rn { +qr 6d|r ftt

-qri y<{n lrnl * Bfrlr{r{t d6!rqsq'q il,friiq El h'sir 5q i a-a;ra qw iR-a rdn/lnf't I nQ qt{ * qc-{ tftd f{i d Rnff r+n cff qsrlqr{ tti rr qr *qr cq'd # dlt ltrd'fiNE6E rr€ qrfl d FFFI nr< itr{ iFnl

And I further agree lhal if after the date of submission of th€ proposal bin before the issue ol the First Premium ReceiDt (i) any du|ro€ in myoccupation or any.adverse circumstanc€s connected with my tinandal position or the g€ngral health of myself or that of any mem'Oed ot riy tamif occur691,(!il lf 3 proposalfgr Psurance oran application for rei/lval ot pollcy on my life made to any otlice of tho Corporation his been wittrOraim or &o9peC,doterred or accepted.at an increasod promium or subiect to lion or on tems other than as proposed. I shall torthwith idimate the same lo the Copoiiilonin wjiting to reconsidor the terms.of accepiance of a-ssuranc€. Any ofiissiooon my pad lo do so shall render this assurance invalid and all moo+ whichthall have been paid in respect thereol shall stand forteited to the Conoration.

rVDated at.....................................................F:lioTon the...........................,,..qI6lday of.,...........................20wfr S Fttlltrt/Signature of Witness[......qfiryO/Occupation........

r f f l I ,zAddress . . . . . . . . . . : . . . . . . . . . . . . .

(1) srd T{i srd q'fu artr q}qqr (qR sffic strr Silur Ferls{Fff/ili*dl + 3rRFn €rr4 fr'qft rns| { ftq'rq t)Declaration by the person filling the form (in case form is filled up / signed in alanguage different from that of the proposalform )rtlqutr+af ?Fr qrq qq qdr Declarant,s Name & Address

{ q q r F n r r m t d 4 / / f . ' . . ' . . ' . . . ' . . . . . . ' . . . . - . - . . . . : . : : : ; ' . ' . . - - : : : : . : ' . . ' . . ' . . , . . . . ' . . ( c c / q { f q q F d ) . ' e I r I 5 I { n | ! ITKr+qI + Ayc rrrf T* qd qih rsrgr Rqrrqr t Rr +{ rflFd o-giq d qrer o} vqs ftqr t rl C€n[y AEt tho conl€nt of thand I have under6lood thE eignmcanco of the proposed contracl,

(2) qR lr.ffrco 3rilrq t I ln Case the Proposer is iiliterate:e'KrqiF al oiTdr fur+ Rnfi t* sRfud qfu am FrsfrtqEEnq rr{fliTr * 6t n6,ff d *{ Eil ftIrq t qqRrf, c Ei,crrFrd ol rilr$ qrRq tHis/her Thumb impression should be attested by a person of standingwhose identity can easily be established, but unconnected with theCorporation and this declaration should be made by him.M irT ;Tfq Cq qdr Declarant's Name & Address

{ rqrftd 6tar { fr lrfrr+o i w don fuq ft {s sr{ S cla t o dqr sq+ qr< + rr{t $wtfl vin nfr sE frd'ri t ft ilgctiil lmi wrrc fri7eiqc| dtu frilr{ d'rrqt r

S I certify that the proposer has digned/put his/her thumb impression in my presenceI after admitting that all the answers to question No. 10 and onwards ol this form have

F been correctly recorded.oo

fiq d qrdrfud qfrf, d Er<ren qr crrlgr ft{nrsignature or thumb impression ol the Person on whose life is proposed to be assured(1) p vrqem dfq o,inr /o,-{S d fu +i rirnrao qn sr*n crc q-#rfifr

Fr$r fri t sltr vsd Erfl fri Tn srrl Et 6 va rrq frrfl tI hereby declare that I have fully explained the above questions to the Proposerand I have truthfully recorded the answers given by the Proposer.

""""""'1"" """"""""': '*i d q-.drhf, qfu d F{f,ren qt errla ftcrn

Signature or thumb impression of the Person on whose lile is proposed to be assured(21 t gqarfl tilRa o,im /?E"rd {, fu fi etfl?riF o} rsn trr + Ryq rE ?Fr

cni (qrcr).... .....{ vursr ftqr t sllr ssems'i Gd rrftfi'R lrqilid erE ff rt<n 't;t rrr ftmq ilmr t tI hereby declare that I have fully explained the above questions and contents of thisForm to the Proposer in...........................1an9ua9e and that the proposer has affixedthe thumb impression above after fully understanding the contenls thereof.

s[fufi'rq tre /Authority Letter{ ...................qffffilft.S.fl.tl./frorsqffiS/g*$/grrff ...........u1ntuqdCI1irql1.. , . . . . . . . . . , . . . . . . . .authorise my Agent/CLIA/Dev. Off icerShrUSmul(um........ ............1o collect my policy bond bearing

ffqrtrVewr+fi qi F€rarr/Life Assured /Proposer'e signature

;lFlilame

ERTIS{/Signature

+qr crfufrqq rgss d Em es (wriu) suMMARy oF sEcloN 4n oF tNsuRANcE Acr, 1938{fr$ itrr* !}i q} qf c{ e} qrlrd +{i *qt d As0 { qrFrff q{ ftql 6f Em qr qten q-r Efrfu{ rfl cqrql qq'n ffr *qr rrsn ql Ffu6m sM qrtdq- f f f ! c )h - rqnF iH i lq rqq f f iE f i r lqGr r iv renwvRnf fv r0g i , toErqn ' rceqrq*scrqr ; { r f f i i a tnaotes-€T i ra-6-dr!t// fuo-rlt dR dtFBfl era em cE rqrr oc,.flI*qr frqrrqr q dla dFr$-rtd clrqn ti sqq qt qrqr qr ft c! Tqr< qi-d t ql cr rcrr q{ ;16€$!.n 6r Ecrfl I fiFF r TrqT t|FlI ql|Inrf, TFd|I4 rut rtlf.tqr qrlfuq"ft : ireloi or ori - qr<swi Er o{ n s'ErS 6.{dr t ft, rqff qrd$, crcs6, {<fun qrrr{, q} fiTc Em R}fu{ d qrfm f{i * {qfud cI INo policy of lile insurance sh8ll, atler the expiry oI twg years from the date on which it was eftected, be called in qu€$tlon by an insurer on the g@und thata 9latement made in the proposal lor insurance or in any report ol a m€dical offic€r, or referee,.or friend of the insured, orln any other docum-ent leadinglo tne issue ol the policy, lvas haccurate or talse, unless the insurer shows thal such slatem€n| was on a materlal matter or sirpffessed facls which itwaa material to disclose and lhat it was fraudulently madE by the policyholder and thal lhe pollcyholder knew at lhe time ot makiitb it lhat the stiatementwas false or lhat it suppressed tacts which it was matedal to dlsclosil.Note : "Malerial' shall mean and include all important, essential and retevent Iniormatlon in lhe context ot unde.writing the risk to be covered by thecorporation ffqr ififffiTq rgsa d qnr 4t (qnilt) lNsuRANcE Acr 1938 uNDER sEcIoN 41 (st MMARylo)ffi qRq el, ffi { qfu am 3i qrGr$ ii q< qr qnl vqi qi, Frsd qnn il Rrc vqRqr *+ror q}fuq RF< t}, rsa qr qriq Fq i tq a'*rn q q.rd frrfr'

rrq El flfrqq {fu d gq +i_Et qr rd}T{6r rFrs ti d ogqh cff t r qO rA clftr$Ai lrfl ql qroTqi crdr q6s ffi em rolftd flfrr l *qqgiiNfrR6fq frrS { rfi ci Ee d6R r{ |qft.'.dfrzgq *c-r ffirfrdr|rfir{-em qqn Sc" y{ d T{ q|ffic{ uftrq ?i} qs rd qrdvrn.Il qe r-€rE sfliER q} qqq qMA{c !fr{i *qr rarron ftdRard dl Er F{A En +cF-di errl fuqn qclFro +ql qM,4fs *fi rftql ridrEcn El I

(2) at{ S qfu s{+ff crqsrr ut adqr c'Yi gq cd wi vs 500 F do d qcF{ Ilffr t qFfd fuqr qI (fifl tl(l)No person shall sllow or otfer lo allor.y, eithei dkoctly or indirsctly, as an inducomenl to any porson to take oul or rcnow or continue an insurance in

respecl of any kind of d8k tglaling lo lives or propedy h India, any rEbata ot th€ whole or pai of th6 commbsion payablg or any rebate ol the premiumshown on the policy, nor.shall dny person taking out or renewlng or contnulng a policy accept any rebats, Excdpt'such rebalb as may be ailowed inaccordance with thL published prospectus$ or tables of the insurer.Provided thal acceptance by an InusEnc€ agenVCLlA of commi$lon ln connectbn wilh a policy of life insurance kken out by himself on his own lifoshallnot P9 dsemed ro be acceptance of a rebatg ot prsmiun within th€ meaning of thls sirb-s6ction if at the limo of such aftedance the insu.ance

. -. agenVCLlA satislies the ptelcdb€d conditions esl,ablishing that ho is a bortalid€ insulance agsnycllA emdoyed by the insurer.(2)Anyperson making d€taun in complying with th€ provFionE of thb sestion shall b€ punlshabib lytth line vdiicti may-extend to live huidrod rupsos.

dqa srqeq v0eil rrq{ft {Fit d ftg for Medical Case Only