PROPOSAL FOR LIC'S MARKET PLUS PLAN

LIFE INSURANCE CORPORATION OF INDIA
PROPOSAL FOR LIC'S MARKET PLUS PLAN
“IN THIS POLCY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS

BORNE BY THE POLICYHOLDER.”

BRANCH OFFICE:----------------- DIVISIONAL OFFICE
[ ------------ FOR OFFICE USE ONLY ---------]
PROPOSAL NO. : INWARD NO. :
IDENTITY NO. : DT.OF RECEIPT :
POLICY NO.ALLOTED : AGENCY CODE :
NO.OF UNITS ALLOTED : DEV.OFFICER’S CODE :
AMOUNT PAID : IS AGENCY INFORCE? :
AMOUNT PAID ON : AGENCY INFORCE UPTO:
TRANSACTION NO./DATE : IS LICENCE INFORCE? :
CASHIER’S INITIAL : LICENCE INFORCE UP TO:

ALL ANSWERS TO BE FILLED IN BLOCK LETTERS. ANSWERS MUST BE GIVEN IN
WORDS, STROKES OF PEN OR DOTS WILL NOT BE ACCEPTED AS REPLIES.

AMOUNT PAID BY CASH /CHEQUE/DD:

DRAWN ON:
(NAME & ADDRESS OF THE BANK) BANK DRAFT/CHEQUE NO.:

AMOUNT:Rs. (IN WORDS)Rs.

1. a) NAME IN FULL OF LIFE TO BE ASSURED :

b )(i) ADDRESS ( FOR COMMUNICATION ) :
TEL.NO. E-MAIL ID:

(ii) PERMANANT ADDRESS :

c) NOMINEE'S DETAILS
NAME: DATE OF BIRTH/AGE:
RELATIONSHIP WITH LIFE TO BE ASSURED:
ADDRESS:
d) APPOINTEE (IF NOMINEE IS MINOR):
NAME: DATE OF BIRTH/AGE:
RELATIONSHIP WITH NOMINEE:
ADDRESS:

2. PLAN DETAILS
MODE OF PREMIUM PAYMENT: SINGLE PREMIUM/ YEARLY/ HALF-YEARLY/ QUARTERLY

WHETHER RISK COVER IS REQUIRED: YES / NO

IF YES, THEN PLEASE SPECIFY:

a) SUM ASSURED UNDER BASIC PLAN :Rs. (IN WORDS) Rs.

b) ACCIDENT BENEFIT SUM ASSURED : Rs.

c) TOP-UP PREMIUM : Rs. (IN WORDS) Rs.

d) FUND SELECTED: BOND/ SECURED/ BALANCED /GROWTH FUND :
(See information below)

INVESTMENT PATTERN OF THE FUNDS
Fund Type
Investment in Government / Government Guaranteed Securities/ Corporate Debt

Short-term investments such as money market instruments
(including Govt. Securities & Corporate Debt)
Investment in Listed Equity Shares
Bond Fund

Secured Fund


Balanced Fund


Growth Fund
Not less than 80%

Not less than 65%


Not less than 50%


Not less than 20%

100%

Not more than 85%


Not more than 70%


Not more than 40%
Nil

Not less than 15% and not more than 35%

Not less than 30% and not more than 50%

Not less than 60% and not more than 80%
(If fund is not selected, it will be treated as SECURED FUND)

f) OTHER DETAILS:

PLAN NO.
Date Of Birth Of Life Assured
AGE
TERM
VESTING DATE
MODE
AGE PROOF

OCCUPATION
ANNUAL INCOME
SOURCES OF INCOME
SEX

RURAL/URBAN
FIRST/SUBSEQUENT

NATIONALITY
DISTRICT
TALUKA
VILLAGE


3. DETAILS OF EXISTING POLICIES INCLUDING UNIT-LINKED POLICIES PLAN (INCLUDING POLICIES SURRENDERED/LAPSED DURING LAST 3 YEARS):

POL.
NO.
INSURANCE COMPANIES FROM WHERE THE PREVIOUS POLICY/ POLICIES HAVE BEEN PURCHASED WITH ADDRESS (IF PREVIOUS POLICIES ARE FROM LIC OF INDIA, GIVEN NAME OF BRANCH/ D.O.)
TABLE
AND
TERM
SUM
ASSURED
ON MAIN
PLAN
TERM ASSURANCE RIDER SUM ASSURED
CRITICAL ILLNESS RIDER SUM ASSURED
MODE
AMOUNT OF ACCIDENT BENEFIT TAKEN
YEAR OF ISSUE
WHETHER ACCEPTED AS PROPOSED AT ORDINARY RATES. IF NOT, THE TERM OF ACCEPTANCE
MEDICAL
OR NON- MEDICAL
WHETHER INFORCE FOR FULL SUM ASSURED
IF NOT, GIVE DUE DATE OF LAST PREMIUM PAID OR DATE OF SURRENDER
4.a ) HAS ANY POLICY ON LIFE ASSURED'S LIFE LAPSED OR SURRENDERED DURING THE LAST 3 YEARS?

b) HAS A LIFE INSURANCE PROPOSAL ON THE LIFE OF LIFE TO BE
ASSURED EVER BEEN
i) WITHDRAWN/DEFERRED/DROPPED/DECLINED :YES/NO
ii) ACCEPTED WITH EXTRA PREMIUM OR LEIN :YES/NO
iii) ACCEPTED ON TERMS OTHERWISE THAN THOSE PROPOSED: YES/ NO

5. FAMILY HISTORY: (To be Filled only if Risk Cover is opted for)

LIVING
DEAD
MEMBER
PRESENT AGE
STATE OF HEALTH
YEAR OF DEATH
AGE AT DEATH
CAUSE OF DEATH
FATHER
MOTHER
BROTHERS
SISTERS
WIFE/HUSBAND
CHILDREN



6. PERSONAL STATEMENT REGARDING HEALTH OF LIFE TO BE ASSURED: (To be Filled only if Risk Cover is opted for)
Personal history
Answer 'Yes' or 'No'
If 'Yes' give full details
(a) During the last 5 years did you consult a Medical Practitioner for any ailment requiring treatment for more than a week?
(b) Have you ever been admitted to any hospital or nursing home for general check up, observation, treatment or operation?

(c) Have you remained absent from place of work on grounds of health during the last 5 years ?

(d) Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous system ?

(e) Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Cancer, Epilepsy, Hernia, Leprosy or any other disease ?

(f) Do you have bodily defect or deformity ?


(g) Did you ever have any accident or injury?


(h) Do you use or have ever used
(1) Alcoholic drinks:
(2) Narcotics:
(3) Any other drugs:
(4) Tobacco in any form:


(i) What has been your usual state of health?


(j) Have you ever received or at present awaiting/undergoing medical advice/treatment or tests in connection with Hepatitis B or AIDS related condition ?


(k) Are you wearing glasses? If so, power of glasses:


(l) (a) Missing teeth if any, if so number missing
(b) Are you wearing well fitting denture? If so, for how many teeth?





7. PHYSICAL MEASUREMENTS OF LIFE TO BE ASSURED (IN CASE OF NON-MEDICAL):
Ht.(in cm) ----- Wt.(in kg.) --

8. TO BE ANSWERED IF LIFE TO BE ASSURED IS A MARRIED FEMALE: (To be Filled only if Risk Cover is opted for)
(A)Are you pregnant now ?
Date of last delivery
Have you had any abortion or miscarriage or Caesarean section? If so, give details.
Date of last Menstruation
(B) Husband's Full Name
His Occupation
His Annual Income
(C) Details of Husband's Insurance:
POL.
NO.
INSURANCE COMPANIES FROM WHERE THE PREVIOUS POLICY/ POLICIES HAVE BEEN PURCHASED WITH ADDRESS (IF PREVIOUS POLICIES ARE FROM LIC OF INDIA, GIVEN NAME OF BRANCH/ D.O.)

SUM ASSURED

TABLE AND TERM

PRESENT STATUS OF THE POLICY


9. WHETHER THE TERMS AND CONDITIONS OF THE PROPOSED PLAN HAVE BEEN EXPLAINED TO YOU BY THE AGENT:

YES /NO

10. HAVE YOU UNDERSTOOD FULLY THE TERMS AND CONDITIONS OF THE PLAN YOU PROPOSE TO TAKE?

DECLARATION
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 that if any untrue averment be contained therein the said contract shall be absolutely null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital and / or employer from divulging any knowledge or information about me concerning my health or employment on the grounds of secrecy, 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 I further agree that if after the date of submission of the proposal but before the issue of the 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 policy on my life made to any office of the Corporation has been 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 assurance invalid and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

I hereby give my consent for undergoing medical examinations / tests including test for HIV as required by the Corporation.

Dated at : on the _______ day of __________ 20

Signature of Witness
Name___________________ _____________________
Occupation_______________ Signature or Thumb impression of the person whose life is proposed
Address__________________ to be assured.

In case form is filled up / signed in a language different from that of the Proposal Form:
Declaration by the person filling in the form:
“I hereby declare that I have fully explained the above questions to the Life to be Assured in _________ language and I have truthfully recorded the answers given by the Life to be assured.”

Name of the Declarant:________________ Signature:____________________
Address of the Declarant:_____________________
___________________
___________________

Declaration by the Life to be assured:
“I certify that the contents of the form and documents have been fully explained to me by Mr / Ms:__________________________________ and I have understood the significance of the proposed contract.

Signature or thumb impression of the person whose life is proposed to be assured:___________________________
___________________________________________________________________________

In case the Life to be assured is illiterate, the thumb impressions of the Life to be assured should be attested by a person of standing whose identity can easily be established, but unconnected with the Corporation and this declaration should be made by him/her.
“I hereby declare that I have fully explained the above questions and contents of the proposal form to the life to be assured in ______________language, and that the life to be assured has affixed his / her thumb impression above after fully understanding the contents thereof.”

Name of the Declarant:________________ Signature:____________________
Address of the Declarant:_____________________
___________________
___________________

AUTHORITY LETTER

I,________________________ authorise my Agent / Dev.Officer Shri / Smt / Kum _________________________ to collect my policy bond bearing no. _______________
under LIC’s Market Plus.

Life Assured / Proposer's signature
Name :__________________________


SUMMARY OF SECTION 45 OF INSURANCE ACT, 1938

No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose.

Note: "Material" shall mean and include all important, essential and relevant information in the context of underwriting the risk to be covered by the Corporation.
Insurance Act 1938 under Section 41
1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.

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

2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.
N.B. Rebate of premiums shall be allowed only in accordance with the details given in the prospectus or table of premium rates or, as the case may be, the relevant document, and that an offer or acceptance of any other rebates shall be an offence under Section 41 of the Insurance Act, 1938.
For Medical Cases only
"I certify that the Proposer has signed/Put his/her thumb
impression in my presence after admitting that all the
answers to Questions Nos.6 and onwards of this form
__________________________ have been correctly recorded."
Signature of Thumb impression
of the Life Proposed


N.B. Signature or thumb impression should be __________________________________________
Affixed in the presence of Medical Examiner. (Signature of the Medical Examiner)