Proposal Form For LIC's Jeevan Akshay - II (Table No. 163) 1
Proposal Form For LIC's Jeevan Akshay - II (Table No. 163) 1
- Oct 2003)
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Branch Office ..
Proposal No.
Amount of Deposit:.. BOC No..
Date .
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Agent's Name Code No. .
License No. .... Date of Expiry .. Club Membership(CM/ZM/DM/BM)
Tel.No.. D.O's Code No. D.O's Tel.No. ..
(All answers to be filled in legibly. Answers must be given in words. Strokes of pen
or dots or dashes will be accepted as answers aTick appropriate box wherever
applicable).
1. (a) Name in full of the person proposing to purchase the Annuity ----------------------
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(b) Present Address ---------------------- (c) Permanent Address -----------------
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Tel.No. ---------------------------------- (e) Age
E-mail -----------------------------------
2. (a) Name in full of the Annuitant, i.e. the person on whose life, annuity payments
depend ------------------------------------------------------------------------------------------
(b) Present Address ---------------------- (c) Permanent Address -----------------
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(d) Sex: Male/Female (e) Nationality ----------------
(f) (i) Age at last birthday ---------------------- (ii) Date of Birth ------------------------
(iii) What proof of age is being furnished with the proposal --------------------------
Address ..
. .
Signature of the Annuitant
If the answers to the questions in this form and the signature are in a language other
than the one in which the proposal form is printed, then the Proposer should declare
in his own handwriting above his own signature that all questions were explained to
him and that his answers were given after fully and properly understanding the
same.
In case the proposer is illiterate:-
1. The declaration should be made by the 1. I hereby declare that I have fully
person filling in the form. explained the above questions to
Name and . the proposer and I have truthfully
Address of the recorded the answers given by
Declarant . the Proposer.
.
Signature
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.
(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.
..
Specimen Signature of the Annuitant
Agent's Report
I hereby declare that the foregoing statements are true and correct to the best of my
knowledge and belief.
Further, I declare that the above proposal is secured by me and that I have fully explained
the contents of the proposal form to the proposer.
..
Signature of the agent