LIFE INSURANCE CORPORATION OF INDIA (Estd Under LIC Act 1956) Mr.

Selvakumar
FORM FOR SUITABILITY ANALYSIS Access Id : 765136275

Proposer Full Name Date of Birth Age Marital Status Occupation

Details : Mr. Selvakumar 27-09-1992 32 Married 27-Office goers/Shop employee/Service p

Address : Flat # 4B , No 15 First floor ,, Vijayanagar , 1st cross st, Velachery, Chennai, 600042

2. What is proposer's yearly income from: ( ** if life assured is different from the proposer)
Employment Business / Profession Other Sources H.U.F. If any Income of life to be assured **
0 0 0 0 0
3. Whether income proof submitted ? (If Yes, give details below) No
Nature of Document for income verification Is he/she Income Tax Assessee If yes, please provide PAN & Income Tax Bracket

No Income Proof submitted Yes CQDPM1720L Nil

4. Previous Insurance Details (Please refer annexure)
5. Family History (Please refer annexure)
Spouse Details
Name Occupation Annual Income
R. Geetha N.A. N.A.
6. Need Analysis
Total Annual Income Outstanding Liabilities
0 Secured Loans 0 Non-secured Loans 0
Based on his age and income, the maximum insurance that can be granted is :
Age Group Multiple of Avg. Annual Income Maximum allowable Insurance
Up to 35yrs 25 times 0

7.
Object of Insurance How would you like to pay your premiums
Risk Coverage with savings Regular
Risk Profile Time frame for this investment
Conservative to Moderate 18
8 Categorization of Plans in relation to object of Insurance
Category Risk Profile Plan Name
Conservative to Moderate Conservative to Moderate JEEVAN LAKSHYA

9 Product Chosen
Table No Plan Name Term Sum Assured Mode Premium
933 LIC's Jeevan Lakshya 18 500000 Quarterly 8517

a) If ULIP is proposed :
Allocation Charges Other Charges (which will be levied by cancelling Units)
Ist Year Iind Year IIIrd Year onwards Life Cover charges Policy Administration Charges Fund Management charges
N.A. N.A. N.A. N.A. N.A. N.A.
b) If Annuity / Pension is proposed :
Target Annuity per annum Type of annuity Annuity Amount per annum Deferment Period
N.A. N.A. 0 N.A.

10. Is the total insurance added to the present proposal is reasonable in relation to income Yes

The questions above pertain to your personal condition at the time of application and 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, Mr. Selvakumar having received the information with respect to the above , have understood the
selection of product before entering into this contract. My preferred plan details are as following:

Table No Plan Name Term Sum Assured Mode Premium

933 LIC's Jeevan Lakshya 18 500000 Quarterly 8517

09-08-2024 01:16:47
 LIC's Jeevan Lakshya (Plan No. 933)

Benefit Illustration

LIC's Jeevan Lakshya (Plan No. 933)

A Non-Linked, Participating, Individual, Life Assurance Savings Plan
(Unique Identification Number - 512N297V02)

Distribution channel Offline Agency name Agency code

Name of Age of 32 years Date of illustration 09-08-2024
prospect/policyholder prospect/policyholder
Name of life assured Age of life assured 32 years Benefit UID/Proposal no. ON310487484116
Mode of payment of
Policy term 18 years Premium payment term 15 years Quarterly
premium

Basic sum assured Rs. 5,00,000 Sum assured on death1 5,50,000 Instalment premium 8,006.00
(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 Riders2 Total instalment premium
Instalment premium without GST 8,006.00 8,517.00
Instalment premium with GST @ 4.50% (1st year) 8,366.00 8,900.00
Instalment premium with GST @ 2.25% (2nd year onwards) 8,186.14 8,708.63
GST rate shall be as applicable from time to time

Page 1
 LIC's Jeevan Lakshya (Plan No. 933)

(Amount in rupees)

Total benefits (including guaranteed and non-guaranteed benefits)

Non-guaranteed Non-guaranteed
Guaranteed benefits benefits @ 4% p.a. benefits @ 8% p.a.
Maturity benefit Death benefit5 Surrender benefit6

Death benefit
Annualized Maturity Maturity Death Death
premium3 Total benefit, benefit,
Policy year (cumulativ benefit7, benefit7,
income incl. of incl. of incl. of incl. of
e) benefit final final Surrender Surrender
Surrender Lumpsum Maturity Reversiona Surrender Reversiona Surrender final final
payable in payable additional additional benefit @ benefit @
benefit on benefit ry bonus benefit ry bonus benefit additional additional
equal bonus bonus 4% (3+8) 8% (3+10)
date of bonus bonus
instalment maturity 1 (FAB), if (FAB), if (FAB), if (FAB), if
s over o/s any, @ 4% any, @ 8% any, @ 4% any, @ 8%
term after (6+7+FAB) (6+9+FAB)
death4
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16)

1 31354 0 850000 550000 0 4000 0 15500 0 0 0 622000 836500 0 0

2 62708 18812 800000 550000 0 8000 0 31000 0 0 0 622000 836500 18812 18812

3 94062 32922 750000 550000 0 12000 2044 46500 7919 0 0 622000 836500 34966 40841

4 125416 62708 700000 550000 0 16000 2813 62000 10900 0 0 622000 836500 65521 73608

5 156770 78385 650000 550000 0 20000 3516 77500 13625 0 0 622000 836500 81901 92010

6 188124 94062 600000 550000 0 24000 4238 93000 16424 0 0 622000 836500 98300 110486

7 219478 109739 550000 550000 0 28000 4998 108500 19367 0 0 622000 836500 114737 129106

8 250832 132941 500000 550000 0 32000 5811 124000 22518 0 0 622000 836500 138752 155459

9 282186 158024 450000 550000 0 36000 6696 139500 25947 0 0 622000 836500 164720 183971

10 313540 184989 400000 550000 0 40000 7672 155000 29729 0 0 622000 836500 192661 214718

11 344894 213834 350000 550000 0 44000 8769 170500 33981 0 0 622000 836500 222603 247815

12 376248 244561 300000 550000 0 48000 10008 186000 38781 0 0 622000 836500 254569 283342

13 407602 277169 250000 550000 0 52000 11435 201500 44310 0 0 622000 836500 288604 321479

14 438956 311659 200000 550000 0 56000 13093 217000 50735 0 0 622000 836500 324752 362394

15 470310 348029 150000 550000 0 60000 15030 232500 58241 0 0 622000 836500 363059 406270

16 470310 362139 100000 550000 0 64000 17318 248000 67109 0 0 622000 836500 379457 429248

17 470310 423279 50000 550000 0 68000 20400 263500 79050 0 0 622000 836500 443679 502329

18 470310 423279 0 550000 500000 72000 25200 279000 97650 572000 786500 622000 836500 448479 520929

Notes:

Page 2
 LIC's Jeevan Lakshya (Plan No. 933)

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. Lumpsum payable on date of maturity, on happening of death in any of the policy years, is actually payable only at the end of the policy term.
2. It includes rider(s) premiums in respect of all the rider(s) opted by the proposer/policyholder at inception of the policy.
3. 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.
4. In case of death of the policyholder during the policy term, annual income benefit equal to 10% of basic sum assured shall be payable from the policy anniversary
coinciding with or following the date of death of the life assured, till the policy anniversary prior to the date of maturity. In addition to this, an amount equal to 110% of basic
sum assured (as mentioned in column no. 5) shall be payable on due date of maturity on happening of death in any of the policy years.
5. In any case, the total death benefit i.e. the sum of total income benefit and lumpsum amount payable on maturity shall not be less than 105% of the total premiums paid
(excluding GST, extra premium and rider premiums, if any).
6. Special surrender value may however be payable, if it is more favourable to the policyholder.
7. Total death benefit shall be equal to the lumpsum payable on date of maturity plus vested reversionary bonus and final additional bonus, if any, payable on maturity.

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 Date : Signature of prospect/policyholder

Page 3
 Proposal Form

PROPOSAL FORM
Recent
Plan Name LIC's Jeevan Lakshya Plan No 933 UIN 512N297V02 passport size
photograph of
Proposal No. 800114 Proposal Date 09-Aug-2024 BranchCode 76V the proposer

Access_Id 765136275 Agency Code 0284676V D.O. Code 1126076

Email Id [email protected] Mobile No. *9677030297

* 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.
▼ Details of plan proposed
Term & PPT Sum Assured Premium Mode of Payment Date of commencement
18-15 500000 8517 Quarterly 09-08-2024
AB/ADDB Req AB/ADDB Sum Assured C.I. Sum Proposed T.R Sum Proposed PWB Rider Req
ADDB-Yes 500000 0 500000 No
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 paramilitary force? Yes ✔ No
If “Yes”, (ii). Whether you wish to avail the AB/AD& DB rider while on police duty? Yes ✔ No
Applicable for SSS Policies only

PA Code and Dept No. Badge or SR No.

I undertake to undergo all the medical tests as may be prescribed / required by the Corporation for the grant of insurance.

▼ Personal details of the life to be insured

1. Name` Mr. Selvakumar

2. Father's Name R.Mani 3. Mother's Name M. Anjali

4. Gender ✔ Male Female Third Gender

5. Marital Status Married 6. Spouse Name R. Geetha

7. Date of birth 27-09-1992 8. Age 32 years.

9. Age Proof Aadhar with full DOB 10. Place of birth Tindivanam

11. Residential Status Resident Indian 12. Citizenship India

▼ Communication details
13. Present Address for communication 14. Permanent Residential Address

Address Line 1 Flat # 4B , No 15 First floor , Address Line 1 5/3 Avvaiyar Street Tharamani TTTI

Address Line 2 Vijayanagar , 1st cross st, Velachery Address Line 2 Taramani Chennai Tamil Nadu

Address Line 3 Chennai Address Line 3

PIN Code 600042 PIN Code 600113

Phone (Landline) 00 Phone (Landline) 9677030297

▼ KYC particulars
1. Are you an IT Assessee If yes, provide 2. PAN CQDPM1720L
✔ Yes No

3. Proof of Identity Aadhaar Card/e-Aadhaar Card 4. Address Proof Aadhaar Card/e-Aadhaar Card

5. Are you (Proposer) registered under the GST act ? Yes ✔ No

If yes, provide GSTIN

6. Central KYC Registry No. 0

2024-08-09 Page 1 of 9
 Proposal Form

▼ Occupation Details

1. Present Occupation Office goers/Shop employee/Service 2. Exact Nature of duties Service

providers with tax

3. Name of present employer 4. Length

Omega Healthcare Management Services Privateof
Ltdservice
L 132 months

5. Annual income 1000000 6. Source of income Employed(Salary)

7. Educational Qualification Graduate Or Post Graduate 8. Purpose of Insurance Risk Coverage with savings

8. Are you employed in armed forces? Yes ✔ No

(If your answer is 'Yes', please provide the following details:

(a) Wing to which you (b) Date of last medical

belong? examination

(c) Rank therein (d) Medical category after

medical exam

(e) Were you ever (f) If yes, when.

below A-1 category? (please provide date)

▼ Other details
1. Is your occupation associated with any specific hazard or do you take part in hazardous activities or have
hobbies that could be dangerous in any way? Yes ✔ No
If yes, provide details

2. Have you ever been or are currently being investigated, charge sheeted, prosecuted or convicted or having Yes ✔ No
pending charges in respect of any criminal/civil offences in any court of law in India or abroad ?
If yes, provide details

3. Are you Politically Exposed Person ( PEP as per RBI Guidelines PEPs are the individuals who are or have Yes ✔ No
been entrusted with prominent public functions in a foreign country. )

If yes, provide details

▼ Lifestyle details
1a.

Do you smoke / consume or have you ever Yes / No If YES, Quantity consumed If STOPPED,
smoked / consumed the following (i , ii, iii) and Duration Since how may months

(i) Alcoholic drinks Yes ✔ No

(ii) Narcotics Yes ✔ No

(iii) Any other drugs Yes ✔ No

1b.

Do you smoke/consume or have you

smoked/consumed tobacco in any form
( cigars, cigarettes, beedis, pan masala etc) Yes ✔ No
in the past 60 months.(in sticks/packets/
sachets/gms per day)

2. What has been your usual state of health? ✔ Good Not Good

If 'Not Good', please mention the health issues

2024-08-09 Page 2 of 9
 Proposal Form

▼ Details of previous policies held / proposals applied

1. Previous policy details not provided

2. Is your life now being proposed for another assurance or an application for revival
of a policy on your life or any other proposal under consideration in any office of Yes ✔ No
Life Insurance Corporation of India or to any other insurer?
If yes, please give details

3. Whether proposed simultaneously on the life of spouse and children ? Yes ✔ No

If yes, please give details

4. Has a proposal (or an application for revival of a policy) on your life made to any office of Life Insurance Corporation
of India or to any other insurer ever been:

(a) Withdrawn, Deferred, Dropped or Declined? Yes ✔ No

If yes, please give details

(b) Accepted with extra Premium or Lien? Yes ✔ No

If yes, please give details

(c) Accepted on terms otherwise than those proposed? Yes ✔ No

If yes, please give details

(d) Have you during past one year returned any policy of Life Insurance Corporation of Yes ✔ No
India as the same was not acceptable to you?

If yes, please give details

▼ Medical details of the life to be insured

1. 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.
a). Lungs/Respiratory disease/Persistent cough, asthma, bronchitis, pneumonia, spitting of blood etc. Yes ✔ No
b). Hypertension, Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, any disease of the heart Yes ✔ No
or arteries
c). Peptic ulcer/colitis, jaundice, anaemia, piles, dysentery, or any other disease of the stomach, liver, spleen, gall Yes ✔ No
bladder or pancreas/digestive disorder

d). Any disease of kidney/prostate or urinary system Yes ✔ No

e). Paralysis/epilepsy/insanity/tremors, numbness, double vision, dizzy or fainting spells/head injury /insomnia Yes ✔ No
/nervous breakdown/any other disease of the brain or the nervous system
f). Hernia/hydrocele, varicocele, fistula, varicose veins, filariasis, gonorrhoea, syphilis or any other veneral disease Yes ✔ No
g). Cancer/leukemia/lymphoma/tumour/cyst/ any other growth/lumps/blood disorder/enlarged glands. Yes ✔ No
h). Any disease of ear, nose, throat or eyes, including defective sight or hearing and discharge from the ears Yes ✔ No
i).Endocrine disorders such as Diabetes, Goitre, Thyroid etc or have you ever passed sugar, albumin, pus or blood Yes ✔ No
in urine
j). Bone / Joint / Spine disease / Arthritis Yes ✔ No
k). Mental Disorder (Depression/Anxiety etc) Yes ✔ No
l). Chronic infections - Tuberculosis/pleurisy/skin disease/skin eruption/leprosy Yes ✔ No
m). Hepatitis or AIDS & HIV related condition Yes ✔ No
n). Any operation, accident or injury/any bodily defect or deformity Yes ✔ No
o). Any other disease ? Yes ✔ No

2024-08-09 Page 3 of 9
 Proposal Form

▼ Medical History of the life to be insured

2. Height (in cms) 178 Weight (in kgs) 88

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

▼ Family Medical history

1.Have your parents / spouse / partner / children and/or any of your relations ever suffered from or died of heart
disease, stroke, high blood pressure, diabetes mellitus, cancer, kidney disease or any hereditary disorders, Yes ✔ No
Insanity, or any contagious diseases such as tuberculosis ,hepatitis, AIDS / HIV etc.?

If yes, please specify

a. Name of the disease

b. Relationship with the life to be assured

c. date / year of death

▼ Family history
Please refer to annexure “Family History”
▼ Female Life (if applicable)
Please refer to annexure “Female Life”
▼ Settlement Options (as per plan conditions)
1. Do you wish to avail “Option to take Maturity Benefit in Instalments Yes ✔ No
2. Do you wish to avail “Option to take Death Benefit in Instalments Yes ✔ No
If yes, please refer to annexure “Settlement Option(Maturity) and Death Benefit Option”

▼ Bank details of the life to be insured

1. Your bank account type ✔ Savings Current 2. Account Number 603301524127

3. IFS Code ICIC0006033 4. Bank Name ICICI Bank

5. Bank Address Branch :CHENNAIBESANT NAGAR : ICICI Bank Ltd., E.32, II Avenue, Besant Nagar, Chennai.600090,
Tamil Nadu

▼ Premium Waiver Benefit

To be answered only if proposing for “LIC’s Premium Waiver Benefit Rider ” in case of insurance on Minor Life

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

Do you agree with the above Yes No

Note: Proposal shall be considered for LIC’s Premium Waiver Benefit Rider only , if your answer to the above question is “Yes”

2024-08-09 Page 4 of 9
 Proposal Form

▼ For Aadhaar Stambh / Aadhaar Shila Plans

To be answered only if proposing under “LIC’s Aadhaar Stambh “ or “ LICs Aadhaar Shila”
.
a. Total existing (excluding the proposal under consideration) sum assured under LIC’s Aadhaar Shila/ LIC’s Aadhaar Stambh :

b. Is your life being proposed simultaneously under the same plan? Yes No

If “Yes”, give details :

Note: The total Sum Assured under LIC’s Aadhaar Stambh or LIC’s Aadhaar Shila on an individual should not exceed Rs. 5 lakhs .

▼ For Jeevan Azad Plans

To be answered only if proposing under “LIC’s Jeevan Azad”
.
a. Total existing (excluding the proposal under consideration) sum assured under LIC’s Jeevan Azad :

b. Is your life being proposed simultaneously under the same plan? Yes No

If “Yes”, give details :

Note: The total Basic Sum Assured under all policies issued to an individual under LIC’s Jeevan Azad (including Basic Sum Assured under this
proposal) should not exceed Rs. 5 lakhs. Any proposal even if inadvertently submitted shall be deemed null and void.

▼ For New Jeevan Amar & Plans where applicable as per plan specifications

To be answered only if applicable as per Plan specifications and for New Jeevan Amar

a. Under which category do you wish to apply? Smoker Non-Smoker

Note: Non- smoker rates will be offered only on the basis of findings of Urine Cotinine Test.

b. Question regarding Death Benefit:

Please select one of the options for Sum Assured on Death (by ticking (a) in the appropriate box) depending upon your specific
needs:
Option I: Level Sum Assured

“Level Sum Assured”, where Sum Assured on Death shall be an amount equal to Basic Sum Assured and shall remain constant throughout policy
term.
Option II: Increasing Sum Assured

“Increasing Sum Assured", where Sum Assured on Death shall remain equal to Basic Sum Assured till completion of fifth policy year. Thereafter, it increases
by 10% of Basic Sum Assured each year from the sixth policy year till fifteenth policy year till it becomes twice the Basic Sum Assured. This increase will
continue under an inforce policy till the end of policy term; or till the Date of Death; or till the fifteenth policy year, whichever is earlier. From sixteenth
policy year and onwards, the Sum Assured on Death remains constant i.e. twice the Basic Sum Assured till the policy term ends.

▼ For LIC's Dhan Varsha (Plan 866)

To be answered only for Dhan Varsha

The options should be chosen carefully depending on the individual’s specific needs as the premium & benefits under the plan shall
vary as per the option chosen and the same shall not be altered later.

Option 1: 1.25 times of Tabular Premium for the chosen Basic Sum Assured

Option 2: 10 times of Tabular Premium for the chosen Basic Sum Assured
Refer Sales Brochure for detailed benefits available under the respective option.

I understand that once Option is chosen the same shall not be altered and shall become part of the Policy Document.

▼ Consent

a) Have you understood fully the terms & conditions of the plan you propose to take? ✔ Yes No

b) Whether the terms & conditions of the proposed plan and any other information that you needed for ✔ Yes No
matching your objectives of insurance have been explained to you by the agent?
Are you registered with LIC Portal: Yes ✔ No
If yes, give Customer ID
N.A.
If not, 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.

2024-08-09 Page 5 of 9
 Proposal Form

▼ For Dhan Sanchay Plan

To be answered only if proposing under LIC’s Dhan Sanchay (Plan 865)
.
The benefits payable under the plan shall depend on the Benefit Option chosen, Policy Term, Premium Paying Term, and Payout Mode. The Benefit
Option should be chosen carefully depending upon your specific needs.

1. Benefit Option: Please select one of the Benefit Options* based on the Premium Payment Type opted (by ticking (√)
in the appropriate box):

Premium Payment Type :

Regular / Limited Premium

Single Premium

Benefit Option :
Option A: Level Income Benefit

Option B: Increasing Income Benefit

Option C: Single Premium Level Income Benefit

Option D: Single Premium enhanced cover with Level Income Benefit

Amount of Premium:

* Refer Sales Brochure for detailed benefits available in the respective Benefit Option.

2. Tick the appropriate Payout Mode for the payment of Guaranteed Income Benefit:

Yearly Half-Yearly Quarterly Monthly

I understand that once Benefit Option, Policy Term and Premium Paying Term is chosen the same shall not be altered and shall become a part of the Policy
contract.

▼For Dhan Vriddhi Plan

To be answered only if proposing under LIC’s Dhan Vriddhi (Plan 869)

The options should be chosen carefully depending on the individual’s specific needs as the premium & benefits under
the plan shall vary as per the option chosen and the same shall not be altered later.
Please select one of the Options for “Sum Assured on Death” (by ticking () in the appropriate box):

Option 1: 1.25 times of Tabular Premium for the chosen Basic Sum Assured

Option 2: 10 times of Tabular Premium for the chosen Basic Sum Assured

Refer Sales Brochure for detailed benefits available under the respective option.

I understand that once Option is chosen the same shall not be altered and shall become part of the Policy Document

▼ For LIC’s Jeevan Kiran (Plan 870)

To be answered only if proposing under LIC’s Jeevan Kiran (Plan 870)

Under which category do you wish to apply? (Tick one of the following):

Smoker

Non-Smoker

Note: Non- smoker rates will be offered only on the basis of findings of Urine Cotinine Test.

2024-08-09 Page 6 of 9
 Proposal Form

▼ LIC’s Jeevan Utsav (Plan 871)

Annexure-12(d)

Addendum to Proposal Form for Plan Specific Details

To be compulsorily filled up if proposing under LIC’s Jeevan Utsav (Plan 871)

The options should be chosen carefully depending on the individual’s specific needs as the
benefits under the plan shall vary as per the option chosen:

Please select one of the following Options (by ticking in the appropriate box):

Option Tick the appropriate box

Option I: Regular Income Benefit

Option II: Flexi Income Benefit

Refer Sales Brochure for detailed benefits available under the respective option .

I understand that once Option is chosen shall become part of the Policy Document.

Signature/Thumb Impression of Proposer/Life to be assured

Note: The policyholder can change the option exercised by him at the inception of the policy at any
time upto six months before the beginning of the policy year in which the first Regular Income
Benefit or Flexi Income Benefit becomes due.

2024-08-09 Page 7 of 9
 Proposal Form

▼ 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 ; 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:

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 Signature of the Agent /

Life to be Assured Intermediary

2024-08-09 Page 8 of 9
 Proposal Form

▼ Declaration of the life to be insured

Selvakumar
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 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 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. 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 as amended from time to time.
I undertake to inform the Corporation immediately of any changes in KYC documents such as residence. I also give my consent to share my data 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/E mail on the below mentioned registered number/ E mail address from / on behalf of the Corporation
with respect to my life insurance policy/regarding servicing of insurance policies/enhancing insurance awareness/ notifying about the status of Claim etc

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

Residence for Tax Purposes in Jurisdiction(s) outside India: Yes/No Yes ✔ No (This point is not applicable for plans 859, 954 and 955)
I hereby declare that the detail furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein
within 30 days of such changes. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be
held liable for it.

Signature of witness

Witness should be a third party (Not related to the life to be insured)

Signature of the life to be insured

Name

Address

Pin Code

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 of the Declarant:..................................................

Address of the Declarant:.................................................. Signature :...........................................

I certify that the contents of the form and documents have been fully explained to me by (Name, Designation, Occupation)
Mr./Mrs................................................................................................................ and I have understood the significance of the proposed
contract.

___________________________________________________________________
(Signature or thumb impression of the person whose life is proposed to be assured:)

2. In case the proposer is illiterate, his/her thump impression should be attestted by a person of standing whose identity can be
establised, but unconnected with the Corporation and this declaration should be made by him.

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.

Name of the declarant :............................................................ Signature....................................................

Address of the declarant.........................................................

Page 9 of 9
 NOMINATION DETAILS
Selvakumar Proposal Form

Access Id : 765136275

▼ Particulars of Nomination

Sl Name of the Nominee Age Relationship Share Full Communication Address of the Nominee with PINCODE.
No to the life (%)
assured

Flat # 4B , No 15 First Vijayanagar , 1st cross Chennai

1 Geetha R 29 Wife 100 600042
floor , st, Velachery

▼ Particulars of Appointee (when nominee is minor)

Sl Name of the Appointee Age Relationship to the Full Communication Address of the Appointee with PINCODE.
No nominee

Page 1 of 1
 FAMILY HISTORY

Selvakumar

Access Id : 765136275

Relationship Living / Present State of Health Age at Cause of Death

Dead Age Death

Mother Living 55 Good 0

Sister Living 23 Good 0

Wife Living 29 Good 0

Father Living 57 Good 0

2024-08-09 Page 1 of 1
 e-KYC DETAILS FROM UIDAI

Access Id : 765136275

▼ Personal Details

Aadhaar No. / Virtual ID : ********8205

Name :` Selvakumar Photo

27-09-1992
Date of Birth : Gender : MALE

▼ Contact Details

C/o.

House / Bldg. / Apt. 5/3 Avvaiyar Street

Street / Road / Lane

Landmark

Tharamani
Area / Locality / Sector

600113
Pincode

Village / Town / City TTTI Taramani

P.O.

Chennai
District

Tamil Nadu
State

Page 1 of 1