Annex - II

APPLICATION FOR LOAN ON SECURITY OF PLI/RPLI POLICY

(Please fill in BLOCK letters)

Service Request No. :

(For Official only)
1 Policy Details (particular of policy against which the loan is desired):
Name of Insurant :
i Policy No. : ii Name of Spouse (in case of Yugal Suraksha Policy) :

Date of Acceptance :
iii Sum Assured : iv
(dd/mm/yyyy)

Date of Maturity:
v vi Amount of Loan required :
(dd/mm/yyyy)

vii Purpose for which Loan is required :

2. Details of Previous Loan taken on this Policy (if any)

i Amount of Previous Loan : ii Sanction No.:

iii Sanction Date: iv Date of final repayment of previous Loan:

3. Missing Credit Premium Details (Please enclose supporting documents): …………………………………………………………

4. Communication Address :

Address :

District : State :

PIN Code : Contact Phone Number :

Aadhar Number : e-Mail ID :

5. Office Address of DDO (For Pay Recovery Policy only)

Name & Designation of DDO : Name of Organization :

Office Address : District & State :

PIN Code : Phone No. & e-Mail ID :

6. Account Details (if payment desired through NEFT/RTGS/Other Credit)

Bank Account Details Post Office Saving Bank Account Details

Account Number: Account Number:

Account Type: Name of Account Holder

Name of Account Holder: Post Office Name :

OR
Name of Bank: CBS Post Office (Y/N):

Branch Name: Pin code/SOL ID

IFSC code:
First page of Pass Book Enclosed (Y/N)
Cancelled Cheque Enclosed (Y/N):
7. Assignment prescribed under Rule 31 of Estate Duty Rules, 1953, in respect of PLI/RPLI Policies assigned to the
President for the purpose of paying Estate Duty:
“I ………………………………………………….. do hereby assign the benefit of all moneys to become payable under the Postal
Life Insurance Policy/Rural Postal Life Insurance Policy No…………………………. assuring the sum of
`……………………………………..(Rs.) to the President of India for the purpose of paying Estate Duty in accordance with the provision
contained in clause (f) of sub section (1) of Section 33 of the Estate Duty Act, 1953, which after my death my estate may become liable to
pay to the Government of India.
Provided, however, that in the event of my surviving the date on which the said policy if so expressed would mature or the policy is
surrendered by me, the benefit of the policy and the right to receive moneys there under shall revert to me as if this assignment had not
been made. It is further agreed that if the policy matures before my death or is surrendered by me, then on my request the Insurer will
upon the delivery of the policy pay all or so much or the sum due to me as may be specified in such request, to the Government of India
under the head “K-Deposits and Advances- deposits bearing interest-other Deposits –Deposits towards payment of Estate Duty” for being
treated as deposits of moneys for the purpose of paying estate duty as provided in clause (g) of Section 33 (1) of Estate Duty Act, 1953
and a receipt of the Government of India shall be an effectual discharge to the Insurer for the moneys so paid to them.
I undertake not to deal with the policy in any way so long as the above assignment is operative, except nominating any person to
receive the balance of the insurance proceeds, after satisfying the Estate Duty demand.
I, hereby certify that no prior assignment of the within policy or any encumbrance against it exists.

Dated ………………… (Signature/Thumbprint of Insurant)

Place : …………………
Witness : ………………………….. Name & Address of witness:- …………………………………………………….……..
….…………………………………………………………………………………………………………………. (Copy of self attested
ID and address proof of witness is enclosed)
8. Appointment of Messenger (if loan application submitted by messenger)*:
I hereby declare that I, …………………………………………(insurant name) am unable to visit post office , being medically unfit
or outside India, for submission of loan application. I appoint Shri/Smt./Ms. …………………………………………. (Name of
messenger) as a messenger for submission of my loan application and request you, please allow him/her for submission of the loan
application along with necessary documents.
Name of Messenger ……………………………………
Signature of Messenger ………………………………..
Signature or thumbprint of Insurant ……………………………..
Signature/Thumbprint of Insurant
Documents Enclosed: Yes/No/ NA (Not Applicable)
1 Self Attested copy of Policy Bond
Document (s) of Credit (if pay policy)
2 Or In case, any premia payment is made in addition to the details available in
Premium receipt book (if cash policy) loan quote
3 Self Attested copy of ID proof of the Insurant
4 Self Attested copy of address proof of the Insurant

5 Loan Repayment receipt Book (in case any loan re-payment is made in addition to the detail available in loan quote)

6 Cancelled Cheque of Insurant Bank Account for Bank Mandate Or self attested copy of POSB Passbook First Page

7 Self-Attested Copy of ID and address proof of Messenger (if messenger appointed by Insurant for submission of Loan
application form)
Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited Hospital
8 Or for Appointing a
Self-Attested copy of passport clearly showing date of departure from India messenger
9 Any other document(s), pls specify …………………………………………………………………………………………
Date: ______________
Signature/Thumbprint of Insurant
In case Insurant is illiterate, there should be two literate witnesses-
Witness Name & Address Signature
Witness 1
Witness 2
For Official Use
Certified that I have checked all the documents enclosed and compared with the original document produced by the
Insurant/messenger and verified the averments made in the Loan application based on these documents and found no
discrepancies.
Date:- Signature of BPM/SPM/PM/ CPC in-Charge
Name:
Designation:
Office Stamp:
 Acknowledgement Slip
(To be filled by BPM/SPM/Post Master/CPC in-charge and Handed Over to Insurant)

Loan Application for Policy No.________________received on ___________with Service Request No.________________and following
documents are received from the Insurant:
Documents Enclosed: Yes/No/ NA (Not Applicable)
1 Self Attested copy of Policy Bond

Document (s) of Credit (if pay policy)

2 Or In case, any premia payment is made in addition to the details available in
Premium receipt book (if cash policy) loan quote

3 Self Attested copy of ID proof of the Insurant

4 Self Attested copy of address proof of the Insurant

5 Loan Repayment receipt Book (in case any loan re-payment is made in addition to the detail available in loan quote)

6 Cancelled Cheque of Insurant Bank Account for Bank Mandate Or self attested copy of POSB Passbook First Page

7 Self-Attested Copy of ID and address proof of Messenger (if messenger appointed by Insurant for submission of Loan
application form)
Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited Hospital
8 Or for Appointing a
Self-Attested copy of passport clearly showing date of departure from India messenger

9 Any other document(s), pls specify …………………………………………………………………………………………

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp: