Proposal form for LIC’s Jeevan Akshay – II (Table No. 163) 1 ___________________________________________________________________ Branch Office ……………………………………….. Proposal No…………………………………………. Amount of Deposit:…………….. BOC No……….. Date …………………. ---------------------------------------------------------------------------------------------------------------- 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 ---------------------- ------------------------------------------------------------------------------------------------------ (b) Present Address ---------------------- (c) Permanent Address ----------------- --------------------------------------------- ----------------------------------------------- --------------------------------------------- ----------------------------------------------- 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 ----------------- --------------------------------------------- ----------------------------------------------- --------------------------------------------- ----------------------------------------------- (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 -------------------------- Form 440 (Rev.- Oct 2003) LIC’s Jeevan Akshay - II Proposal form for LIC’s Jeevan Akshay – II (Table No. 163) 2 3. Description of the Annuity: (a) Please indicate the type of annuity (Choose only one out of five) (i) Annuity during the life time of the Annuitant (without any guaranteed period) ? Yes/No (ii) (a) Annuity for a guaranteed term of years and during subsequent life time of the Annuitant ? Yes/No (b) (If so, state the guaranteed term in years) ---------- (iii) Annuity during the life time of the annuitant with return of Purchase Price on death of the annuitant. Yes/No (iv) Life annuity with annuities increasing at 3% p.a. simple Yes/No (v) Joint life and last survival annuity with annuity reducing To 50% payable to spouse on death of annuitant. Yes/No (b) Mode of annuity instalments to be paid: (b)Yearly/Half-Yearly/ Quarterly/Monthly (Please answer either one of (c) and (d)) (c) Purchase price (c) Rs. --------------------- Or (d) Amount of Annuity Instalment or initial (d) ------------------------- instalment amount in case of increasing annuity 4. Nominee of the annuitant to whom benefits, (i) Name: ------------------------ if any, are to be paid under the policy (ii) Relationship to in case of death of the annuitant. the annuitant: --------------- (iii) Age: --------------------------- (iv) Address: ---------------------- --------------------------------- Proposal form for LIC’s Jeevan Akshay – II (Table No. 163) 3 DECLARATION I/We ……………………………………………………………………..do hereby declare that the foregoing statements and answers are true in every particular and do agree and declare that these statements and this declaration shall be the basis of the contract of annuity between me/us and the Life Insurance Corporation of India and that if any untrue averment be contained therein the said contract shall absolutely be null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation. Dated …………………………….on the …………………day of……………………20 Name of Witness …………………………………. …………………………………….. Signature of Witness …………………………….. Signature of the Proposer (the person proposing to Occupation ………………………………………. purchase the annuity) 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 Proposal form for LIC’s Jeevan Akshay – II (Table No. 163) 4 2. The thumb impression of the proposer 2. I hereby declare that I have should be attested by a person of explained the contents of the standing whose identity can easily be proposal form to the proposer in established, but unconnected with the …………………. language and Corporation and this declaration should that I have read out to the be made by him. Proposer the answers to the questions dictated by the Name ……………………………………. proposer and that the proposer Address of the has affixed his thumb impression Declarant …………………………. to the proposal form after fully ……………………………………………. understanding the contents ……………………………………………. thereof. ……………………………………………. …………………………………….. Signature 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 or a medical officer, or referee, or friend of the insured, or in 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 master 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 prospectuses or tables of the insurer: Proposal form for LIC’s Jeevan Akshay – II (Table No. 163) 5 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. …………………………………………….. Specimen Signature of the Annuitant (ONLY FOR TABLE NO. - LIC’s JEEVAN AKSHAY - II) Electronic Clearing Service (Credit Clearing) (ECS) MANDATE FORM (To be filled in separately for each policy) Annuitant desires to receive payments through Credit Clearing Mechanisms 1. (a) Policy No./BOC _________________________ Date ________________ Purchase Price Rs. _______________ Pension ________________________________ Date _________________ (b) Name of Annuitant:______________________________________________ 2. Particulars of Bank A/c. (a) Bank Name: ______________________ (b) Branch Name: ___________ Address : ___________________________________________________ ___________________________________________________ (c) Tel.No. of Annuitant (i) Office: ____________ (ii) Residence: ___________ (d) 9-Digit Code Number of the Bank & Branch appearing on the MICR Cheque issued by Bank ______________________ (e) Account Type (Saving Bank Account/Current A/c. or Cash Credit) with Code 10/11/13 ______________________ (f) Ledger No./Ledger Folio No.: ______________________ (g) Account No.(as appearing on the Cheque Book) ______________________ Proposal form for LIC’s Jeevan Akshay – II (Table No. 163) 6 I, hereby, declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for the reasons of incomplete or incorrect information. I would not hold the user institution responsible. Date: ___________________ _______________________ Signature of the Annuitant Agent's Report (a) Have you canvassed the Pensioner in Person ? ________________________ If not, state reasons therefore (b) What is the approximate age of the Pensioner ________________________ in your opinion ? (c) Do you recommend the acceptance of the ________________________ Proposal ? 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. Dated …………………………….on the …………………day of……………………20 …………………………………………….. Signature of the agent Prop F – LIC’s Jeevan Akshay-II Form 440
