SPGI Application Form

Annexure-V
Consent letter for LIC’s Single Premium Group Insurance

(UIN: 512N298V01)
(For Lender-Borrower Groups)
The Branch Manager
LIC Of India
P&Gs Unit, Silchar
Sir/ Madam,
Re: Application for membership of SPGI Scheme
1. I LALTHLAMUANA availing a MT/Business loan from your Institution, obtained
a sanction or availing the MT/Business loan, hereby give my consent to become a
member of the LIC Single Premium Group Insurance Scheme, which will be
administered by Mizoram Cooperative Apex Bank Ltd. Lender as Master Policy
Holder.
My details are as below: -
Name of applicant (Borrower) (in capitals): LALTHLAMUANA
Date of Birth : 06.03.1993 (DD/MM/YYYY)
Age (nearer Birthday) as on date : 26 years
Loan Availed /Outstanding as on date : Rs 5,00,000.00 EMI : Rs 11,550.00
Single Premium Amount : Rs 4,100.00
Rate of Interest : 14 % Policy Term: 5 years
2. I hereby authorise you to debit loan account No. 000905880000364 a sum of. Rs.
4,838 (4100 + 738) (Rupees four thousand eight hundred thirty eight only)with your
branch towards the one time single premium.
* The same can be recovered from my Savings/Current Account No
000901820012707
* Please include the premium amount as part of the housing loan amount and fix up
the Equated MonthlyInstalments (EMIs) accordingly and debit the premium to my
housing loan account. (Option for new housing loan members only)
* - Strike out which ever is not applicable.
3. I agree that in the event of my unfortunate demise during the pendency of the
loan, Life Insurance Corporation of India (Corporation) will be sole authority to
consider the claim. Corporation may settle the claim amount as per their rules to the
extent of the outstanding loan balance as on the date of death, in favour of the
Lender. These benefits will be utilized towards the liquidation of the loan amount
under the housing loan provided by the Lender. In the event of any surplus arising
out of the benefits settled by Corporation after liquidating the outstanding amount, I
nominate Sh./ Smt. / Kum. LALHMANGAIHTHANGI who is my Wife (relationship) as
the nominee to receive such surplus amount.
4. I agree to pay the full premium at inception even though the full MT/Business loan
amount will be disbursed by the Lender only in phases.
5. I agree to abide by the terms and conditions of the above scheme.
6. I agree to your conveying the above particulars regarding my admission into the
group insurance scheme to LIC of India.
7. Declaration - I, LALTHLAMUANA hereby declare that I am in sound health and am
not suffering or have suffered from any critical illness or condition requiring medical
treatment, as on date. (The applicants should not have suffered or be suffering from
cancer, AIDS, condition requiring open chest surgery, history of typical chest pain,
kidney failure, brain stroke or paralysis, hypertension, diabetes/raised blood sugar,
liver failure, mental illness or having undergone a major organ transplantation such
as heart, lung liver or kidney. If the applicant had suffered or is suffering from any of
the above critical illness, he/she is not eligible to join the scheme). Corporation will
be within its rights to repudiate the claim in case the information given by me in this
regard is found to be untrue.
I, also hereby declare that the above statements are true in all respects and that I
agree and declare that the above information shall form the basis for admission to
the above scheme and that if any information is found to be untrue, my membership
to the scheme shall be treated as cancelled from my date of joining the scheme and
all claims to any benefit in virtue hereof shall be subject to the provisions of Section
45 of the
Insurance Laws (Amendment) Act, 2015 as amended from time to time.
Dated at Aizawl on the 20th day of May, 2019
Signature of the applicant (Borrower) : ..............................................................

Name of the applicant (Borrower) : LALTHLAMUANA
Father’s/Husband’s name : S/o Zothangzela
Residential Address : Lungdai, Aizawl
Telephone No. : 8794549740
I certify that I have read and understood the contents of the above form. I
certify that the contents of this form have been fully explained to me by
Sh./Smt./Kum. (relationship) ____________________________________________
and I have understood the significance of the contract.
_____________________________________
Signature or thumb impression of the applicant
(Borrower)
Witness
Signature :
Name and address :
To be filled in case of thumb impression / vernacular signature:

I hereby declare that I have explained the above contents of this form to the
applicants in _______________________________________ language and I have
truthfully recorded the information given by the applicant. I also declare that the
applicant has suffixed / affixed the thumb impression above after fully understanding
the contents thereof.
Signature of the declarant : ....................................................................
Name : ....................................................................
Residential Address : ....................................................................
....................................................................
Residential Tel. No. : ....................................................................
No Objection Certificate from co-borrowers (if any):
I/We, 1. ..............................................................................................
2. ..............................................................................................
do not have any objection to Sh./ Smt. ____________________________
a) Joining the Single Premium Group Insurance Scheme mentioned above and
b) One time single premium being debited to the ________ loan Account.
Name of the co-borrower : ..........................................................................
Signature of the co-borrower : ....................................................................

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Annexure-V

Consent letter for LIC’s Single Premium Group Insurance

Signature of the applicant (Borrower) : ..............................................................

To be filled in case of thumb impression / vernacular signature:

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