L I F E I N S U R A N C E C O R P O R AT I O N O F I N D I A

(Established by Life Insurance Corporation Act 1956)

FORM FOR SUITABILITY ANALYSIS

`1. Full Name of the proposer Mr Suraj Pratap Singh

Date of Birth 08-11-2000

Age 21 (years)

Full Address J-307 /2 Keshav Puram Awas Vikas No-1

Kanpur Kanpur Kanpur Nagar Uttar Pradesh

208017

Marital Status Single

2. Occupation Self Employed without Tax

3. What is proposer's yearly income from:

(A) (i) Employment Rs 250000 per annum

(ii) Business or profession Rs 0 per annum

(iii) Other sources(to be specified) Rs 0 per annum

(iv) H.U.F if any Rs 0 per annum

(v) Income of the life to be assured if assured is different from the proposer.

Rs 0 ` per annum

(B) Whether Income proof submitted No If Yes;

(i) Nature of document related to income verification No Income Proof submitted

(ii) Is he/she an Income Tax Assessee Yes ,If Yes

(iii) PAN LCLPS0485F

Tax Bracket Nil %

4. Details of previous Insurance: (Please refer to annexure)

5. Family History : (Please refer to annexure)

5 (A). Spouse details:

Name N.A.

Occupation N.A.

Annual Income N.A.

24-07-2021 01:24:03 Page 1 of 3

6. Need Analysis:
Total Annual Income: 250000
Outstanding Liabilities:
(i) Secured Loan 0
(ii) Non-secured Loan 0

Based on his age and income, the maximum Insurance that can be granted as per existing rule is:

Age group: Up to 35yrs

Multiple of Avg. Annual Income: 25 times
Maximum Allowable Insurance: 6250000

7.(a) Object of Insurance: Risk Coverage with savings

(b) Risk Profile: Conservative to Moderate

(c) How would like to pay your premiums: Regular

(d) Time frame for this investment : 21

8. Categorization of Plans in relation to object of Insurance:

Category: Conservative to Moderate

Risk Profile: Conservative to Moderate

Plan Name: JEEVAN LABH

9. Product Chosen

Table No. Plan Name Term

936 LIC's Jeevan Labh 21

Sum Assured Mode Premium

500000 Yearly 26354

9.(a) If ULIP is proposed, allocation charges:

1st year 2nd year 3rd year onwards

N.A. N.A. N.A.

(b) Other charges which will be levied by cancelling UNITs :

Life Cover Charges % Policy Administration Charges Fund Management Charges

N.A. N.A. N.A.

24-07-2021 01:24:03 Page 2 of 3

9.(c) If Annuity/Pension is opted;

Target Annuity per Annum Type of Annuity

N.A. N.A.

Annuity amount per annum Deferment Period

0 N.A.

10. Is total insurance added to the present proposal reasonable in relation to income ? No

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.

Suraj Pratap Singh

I,.....................................................................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

936 LIC's Jeevan Labh 21

Sum Assured Mode Premium

500000 Yearly 26354

Place: India Signature of prospect

Date: 24-07-2021

24-07-2021 01:24:03 Page 3 of 3

 Life Insurance Corporation of India Product Name LIC's Jeevan Labh (T-936) Date of Illustration 24/07/2021

Basic Plan UIN 512N304V02 Policy Number (to be mentioned after issuance of policy) Benefit UID 23D 0000001085
Particulars Name (LP) Agent Name Agent Code
Age at Entry 21 Policy Term 21 Prem. Paying Term 15 Prem. Pay Mode Yearly
Instalment Premium* (W/O GST) 26104 Annualised Premium* 26104 Sum Assured 500000 Death Sum Assured 500000
Note: GST rate shall be as applicable from time to time Policy Option Bonus Type Simple Revesrsionary and Final Additional Bonus
Instalment Premium With GST(First Year)/GST Rate 27279 / 4.50 Instalment Premium With GST(Second Year)/GST Rate 26691 / 2.25
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.

Total Benefits (Including Guaranteed and Non-Guaranteed

Non Guaranteed Benefits Non Guaranteed Benefits)
Guaranteed Benefits
@ 4% p.a. Benefits @ 8% p.a. Surrender
Maturity Benefit Death Benefit
Benefit
Total Total
Policy Maturity Maturity
Annualized Death Death
Year (End Benefit, Benefit, Total Total
premiums Benefit, Benefit,
of the incl. of incl. of Surren Surren
(Cumulative) Surrend incl. of incl. of
year) Maturity Reversionary Surrender Reversion Surrender Final Final der der
er Death Benefit Final Final
Benefit Bonus Benefit ary Bonus Benefit Additional Additional Benefit Benefit
Benefit Additional Additional
Bonus, if Bonus, if @ 4% @ 8%
Bonus, if Bonus, if
any, @ 4% any, @ 8% (3+7) (3+9)
any, @ 4% any, @ 8%
(5+6+FAB) (5+8+FAB)
(4+6+FAB) (4+8+FAB)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 26,104 0.00 5,00,000 0.00 2,000 0.00 15,000 0.00 0.00 0.00 5,02,000 5,15,000 0.00 0.00
2 52,208 15,662 5,00,000 0.00 4,000 0.00 30,000 0.00 0.00 0.00 5,04,000 5,30,000 15,662 15,662
3 78,312 27,409 5,00,000 0.00 6,000 956 45,000 7,169 0.00 0.00 5,06,000 5,45,000 28,365 34,578
4 1,04,416 52,208 5,00,000 0.00 8,000 1,298 60,000 9,732 0.00 0.00 5,08,000 5,60,000 53,506 61,940
5 1,30,520 65,260 5,00,000 0.00 10,000 1,658 75,000 12,435 0.00 0.00 5,10,000 5,75,000 66,918 77,695
6 1,56,624 78,312 5,00,000 0.00 12,000 2,044 90,000 15,327 0.00 0.00 5,12,000 5,90,000 80,356 93,639
7 1,82,728 91,364 5,00,000 0.00 14,000 2,461 1,05,000 18,459 0.00 0.00 5,14,000 6,05,000 93,825 1,09,823
8 2,08,832 1,09,219 5,00,000 0.00 16,000 2,813 1,20,000 21,096 0.00 0.00 5,16,000 6,20,000 1,12,032 1,30,315
9 2,34,936 1,28,275 5,00,000 0.00 18,000 3,179 1,35,000 23,841 0.00 0.00 5,18,000 6,35,000 1,31,454 1,52,116
10 2,61,040 1,48,532 5,00,000 0.00 20,000 3,570 1,50,000 26,775 0.00 0.00 5,20,000 6,50,000 1,52,102 1,75,307
11 2,87,144 1,69,989 5,00,000 0.00 22,000 3,995 1,65,000 29,964 0.00 0.00 5,22,000 6,65,000 1,73,984 1,99,953
12 3,13,248 1,92,648 5,00,000 0.00 24,000 4,464 1,80,000 33,480 0.00 0.00 5,24,000 6,80,000 1,97,112 2,26,128
13 3,39,352 2,16,507 5,00,000 0.00 26,000 4,987 1,95,000 37,401 0.00 0.00 5,26,000 6,95,000 2,21,494 2,53,908
14 3,65,456 2,41,932 5,00,000 0.00 28,000 5,580 2,10,000 41,853 0.00 0.00 5,28,000 7,10,000 2,47,512 2,83,785
15 3,91,560 2,68,219 5,00,000 0.00 30,000 6,255 2,25,000 46,913 0.00 0.00 5,30,000 7,27,500 2,74,474 3,15,132
 16 3,91,560 2,77,224 5,00,000 0.00 32,000 7,037 2,40,000 52,776 0.00 0.00 5,32,000 7,42,500 2,84,261 3,30,000
17 3,91,560 2,86,230 5,00,000 0.00 34,000 7,949 2,55,000 59,619 0.00 0.00 5,34,000 7,60,000 2,94,179 3,45,849
18 3,91,560 2,95,236 5,00,000 0.00 36,000 9,018 2,70,000 67,635 0.00 0.00 5,36,000 7,77,500 3,04,254 3,62,871
19 3,91,560 3,04,242 5,00,000 0.00 38,000 10,283 2,85,000 77,121 0.00 0.00 5,38,000 7,95,000 3,14,525 3,81,363
20 3,91,560 3,52,404 5,00,000 0.00 40,000 12,000 3,00,000 90,000 0.00 0.00 5,40,000 8,12,500 3,64,404 4,42,404
21 3,91,560 3,52,404 5,00,000 5,00,000 42,000 14,700 3,15,000 1,10,250 5,42,000 8,30,000 5,42,000 8,30,000 3,67,104 4,62,654

Notes:
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. It includes rider(s) premiums in respect of all the rider(s) opted by the proposer / policyholder at inception of the policy.
2. 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.
3. In any case the total death benefit at any time shall not be less than 105% of the total premiums paid (excluding GST, extra premium and rider premiums, if any).
4. Special surrender value may however be payable, if it is more favourable to the Policyholder.

I, ...................................................................... (name), have explained the premiums, and benefits under the I, ...................................................................... (name), having
product fully to the prospect / policyholder. received the information with respect to the above, have
understood the above statement before entering into the
Place: contract.
Date : Signature of Agent / Intermediary / Official

Date : Signature of Prospect / Policyholder

 Proposal Form

PROPOSAL FORM
Recent
Plan Name LIC's Jeevan Labh Plan No 936 UIN 512N304V02 passport size
photograph of
Proposal No. Proposal Date BO Code 23D SO code the proposer

Access_Id 989073245 Agency Code 0109123D D.O. Code 38041

Email Id [email protected] Mobile No. *9807829972

* 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
21-15 500000 26354 Yearly
AB/ADDB Req AB/ADDB Sum Assured C.I. Sum Proposed T.R Sum Proposed PWB Rider Req
AB-Yes 500000 0 0 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. Suraj Pratap Singh

2. Father's Name RAM RATAN SINGH 3. Mother's Name NEERAJ SINGH

4. Gender ✔ Male Female Third Gender

5. Marital Status Single 6. Spouse Name

7. Date of birth 08-11-2000 8. Age 21 years.

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

11. Residential Status Resident Indian 12. Citizenship India

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

Address Line 1 J-307 /2 Keshav Puram Awas Vikas No-1 Address Line 1 J-307 /2 Keshav Puram Awas Vikas No-1

Address Line 2 Kanpur Kanpur Kanpur Nagar Uttar Pradesh Address Line 2 Kanpur Kanpur Kanpur Nagar Uttar Pradesh

Address Line 3 Address Line 3

PIN Code 208017 PIN Code 208017

Phone (Landline) 00 Phone (Landline) 00

▼ KYC particulars
1. Are you an IT Assessee If yes, provide 2. PAN LCLPS0485F
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

2021-07-24 Page 1 of 7
 Proposal Form

▼ Occupation Details

1. Present Occupation Self Employed without Tax 2. Exact Nature of duties Business

3. Name of present employer NA 4. Length of service 2

5. Annual income 250000 6. Source of income Business

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

2021-07-24 Page 2 of 7
 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

2021-07-24 Page 3 of 7
 Proposal Form

▼ Medical History of the life to be insured

2. Height (in cms) 183 Weight (in kgs) 68

3. During the last five years did you consult a Medical Practitioner for any ailment requiring treatment for Yes ✔ No
more 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, Yes ✔ No
treatment or operation?

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 Yes ✔ No
heart disease, stroke, high blood pressure, diabetes mellitus, cancer, kidney disease or any hereditary
disorders, 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 3701802928

3. IFS Code CBIN0285007 4. Bank Name CENTRAL BANK OF INDIA

KESHAVPURAM J505 AVAS VIKAS YOJANA 1 CITY KANPUR 208017

5. Bank Address

2021-07-24 Page 4 of 7
 Proposal Form

▼ 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”

▼ 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. 3 lakhs .

▼ For Jeevan Amar & Plans where applicable as per plan specifications
To be answered only if applicable as per Plan specifications and for 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.

▼ 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 ✔ Yes No
that you needed for matching your objectives of insurance have been explained to
you by the agent?

Are you registered with LIC Portal: Yes ✔ No

N.A.
If yes, give Customer ID

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.

2021-07-24 Page 5 of 7
 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: 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 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.
Any person making default in complying with the provisions of this section shall be punishable with fine which may
extend to ten lakh rupees.

Signature of the Signature of the Agent /

Life to be Assured Intermediary

2021-07-24 Page 6 of 7
 Proposal Form

▼ Declaration of the life to be insured

Suraj Pratap Singh
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.

I also give my consent to receive all communications including policy document at the registered email address provided by me in this proposal form.

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 7 of 7
 SETTLEMENT OPTION (MATURITY) & DEATH BENEFIT OPTION

Suraj Pratap Singh

Settlement Option (for Maturity Benefit) Access Id : 989073245

Do you wish to avail Settlement Option ( for Maturity Benefit) under the proposal ? Yes ✔ No

If yes, please give the following details :

II) Period for Settlement option : NA YEARS

III) Whether Settlement option (for Maturity Benefit0 is required for : NA

FULL / PART of the benefit proceeds ?. of the benefit proceeds
If in PART, specify the amount / percentage of e Benefit proceeds :
NA
Absolute amount :

NA
Percentage of benefit proceeds :

NA
Mode of instalment payment :

Death Benefit Option

Do you wish to avail the Death Benefit in instalments under the proposal ? Yes ✔ No

If yes, please give the following details :

II) Period for option to take Death Benefit in installments : NA YEARS

III) Whether option to take Death Benefit proceeds in installments is required for NA
FULL / PART of the benefit proceeds.

If in PART, specify the amount / percentage of e Benefit proceeds :

NA
Absolute amount :

NA
Percentage of benefit proceeds :

NA
Mode of instalment payment :

For Settlement and Death Benefit Options:

If the Net Claim Amount is less than the required amount to provide the minimum instalment amount (as mentioned below)
as per the option exercised by the Proposer/Life to be Assured, the claim proceed shall be paid in lump sum only.

Mode of Instalment payment Monthly Quarterly Half-Yearly Yearly

Minimum Instalment amount (Rs) Rs. 5,000/- Rs. 15,000/- Rs. 25,000/- Rs. 50,000/-

2021-07-24 Page 1 of 1
 NOMINATION DETAILS
Suraj Pratap Singh
Proposal Form

Access Id : 989073245

▼ Particulars of Nomination

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

J-307 /2 Keshav Kanpur Kanpur Kanpur

1 NEERAJ SINGH 48 Mother 100 208017
Puram Awas Vikas No- Nagar Uttar Pradesh
1

▼ 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

Suraj Pratap Singh

Access Id : 989073245

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

Dead Age Death

Brother Living 23 Good 0

Mother Living 48 Good 0

Sister Living 26 Good 0

Father Living 51 Good 0

2021-07-24 Page 1 of 1
 Suraj Pratap Singh

AGENTS CONFIDENTIAL REPORT/MORAL HAZARD REPORT Access Id : 989073245

▼ Agency Details

Agency Code Name and Address

0109123D Suchita Singh,919919433378

D.O/CLIA/Mentor Code No Club Membership

38041 No Club

▼ Proposer Details

1.Name of Proposer & Age Suraj Pratap Singh 21

(a) How long do you know the proposed?

(b) Are you related to him / her? Yes ✔ No

(c) What is the educational qualification of the life proposed ?

GRADUATE

(d) Whether the life proposed is a Politically Exposed Person NO

(PEP) or a family member or close relative of a Politically
Exposed Person? [As per RBI guidelines, PEPs are individuals who
are or have been entrusted with prominent public functions in a foreigh
country], If yes give details.
▼ Income Details

2.(i)Give Details of Annual Income From Proposer Life Proposed Remarks

(a) Employment 250000 0

(b) Business/Profession 0 0

(c) H.U.F 0 0

(d) Other Sources 0 0

Total 250000 0

▼ Proposer Details

(ii).What proof of income verified by you in respect of income

stated above ?
(a).Whether it is salary sheet or certificate issued by the
employer ?
(b).Whether it is certificate issued by C.A ? What is the
NA
Permanent Account No. Alloted by IT authority ?
(c).Whether copies of income tax returns verified ? What is the
NO
PAN Number ?
(d).Are you personally satisfied with the financial standing of the ✔ Yes No
proposer/life proposed and justify the current proposal ?
(e).Whether KYC/AML norms are fulfilled for the proposer ? ✔ Yes No

(f).Are you satisfied that the proposed and/or proposer is not ✔ Yes No
connected with any terrorist activities ?

2021-07-24 Page 1 of 2
 AGENTS CONFIDENTIAL REPORT/MORAL HAZARD REPORT
Access Id :

3.(a).What is the general state of health of the life ✔ Good Not Good
proposed ?
(b).Does he/she has any physical deformity, impaired
sight or hearing, physical impairment or mental NO
retardation ?
(c).Do you have any knowledge of his/her having
suffered from any illness or injury or undergone any `NO
operation or medical investigation ?
4.Did you discuss with the proposer/Life Proposed the ✔ Yes No
status of previous policies and are you satisfied that no
policy has lapsed within the last three years ?
5.Are you aware of any proposal (or revival of any policy)
NO
of the life proposed having been deferred, declines,
dropped or accepted at terms other than those
proposed ?
6.Are you aware of anything in the occupation, financial
or social position of the life proposed, his/her personal NO
habits or any other circumstances which might be likely
to add to the risk ?
7.Have you explained fully the terms and conditions of ✔ Yes No
the plan to the proposer ?
▼ Under Non-Medical Proposals
Marks of Identification ? MOLE ON LEFT HAND

Exact Physical Measurements Height 183 Weight 68

▼ Declaration

I here by declare that the foregoing statements are true and correct to the best of my knowledge and belief

Signature of the Agent

To be completed by the Dev.Officer/ CLIA / Mentor To be completed by ABM(S) / BM / Sr.BM / CM

I am satisfied with the identity of the party on the I am satisfied with the identity of the party on the
basis of my independent enquiries. I here by declare basis of my independent enquiries. I here by declare
that the foregoing statements are true and correct to that the foregoing statements are true and correct to
the best of my knowledge and belief the best of my knowledge and belief

Dated at ........................on the day of ............ 20.. Dated at ........................on the day of ............ 20..
Name and Designation/Standing (No of years) Name and Designation/Standing (No of years)

Signature Signature

Page 2 of 2
 Name : Suraj Pratap Singh
NOVEL CORONA VIRUS (COVID-19) QUESTIONNAIRE
To be completed by the life to be assured / Proposer (in case of minor life) Access Id : 989073245

I. Is life to be assured under quarantine in last 14 days in view of living with anyone diagnosed with Yes ✔ No
Covid-19? If yes , please give details like location, dates, quarantine period N.A.

II. Has life to be assured serving a notice of quarantine by health/government/airport authority for Yes ✔ No
possible exposure to novel coronavirus (SARS-CoV2/COVID-19) N.A.
If yes , please provide details like location, dates, quarantine period
III. Has life to be assured been advised to be tested or awaiting the result of test for novel Yes ✔ No
coronavirus
(SARS-CoV2/COVID-19) in last 14 days?
IV. Has life to be assured experienced any of the following symptoms, such as any fever, Cough, Yes ✔ No
Shortness of breath, Malaise (flu-like tiredness),Rhinorrhea (mucus discharge from the nose),
Sore throat, Gastro-intestinal symptoms such as nausea, vomiting and/or diarrhoea, Chills, N.A.
Repeated shaking with chills, Muscle pain, Headache, Loss of taste or smell within last 14 days ?
If Yes , provide all investigation and treatment details
V. 1) Is life to be assured a Health Care Worker Yes ✔ No
2) Whether enrolled as Corona Warrior or working in Hospital / clinic with novel coronavirus
(/SARS-CoV2/COVID-19) ward/unit or treating/ in contact with Covid-19 infected individuals, Yes ✔ No

N.A.
3) If yes , please give details of service / nature of duties ?
4) Whether vaccinated Yes ✔ No
Health Care Worker(HCW): Includes Doctors, General Practitioners, Hospital Doctors, Surgeons, Therapists,
Nurses, Pathologist, Paramedics, Pharmacist, Ward Helpers, Individuals working in Hospitals / Clinics

VI. Has life to be assured ever been diagnosed with Covid-19 , If yes state Yes ✔ No
N.A.
a). Date of diagnosis
b). Whether home quarantined/in Covid care center (CCC)/Hospitalised? Home Quarantined Hospitalised ✔ None
c). If hospitalized, name of the hospital where life to be assured was admitted and treated for N.A.
Covid-19.
d). Date of discharge after fully cured N.A.
Please submit discharge summary, all investigation reports including all Covid-19 reports

VII. Is the life to be assured NRI/FNIO/OCI ? If Yes, please give : Yes ✔ No

a) Name of Country of residence N.A.

b) Are you currently residing in India, If yes, since when N.A.

c) Date of return to Foreign country of residence N.A.

X. Has life to be assured been vaccinated for novel coronavirus(SARS-CoV-2/COVID-19), If Yes Yes ✔ No
a). Date of first Dose N.A.
b). Date of second Dose N.A.
c). Name of vaccine
N.A.
d). Have you experienced any adverse reaction post vaccination? If yes, please share
details including treatment taken for adverse reaction (and how many days after Yes ✔ No
vaccination) N.A.
Copy of vaccination certificate (or copy of any official documentation confirming complete
vaccination issued by the relevant health authority)
Please note self-declarations are not acceptable.

Declaration
I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any material
information that may influence the assessment or acceptance of this proposal. I agree that this form will constitute part of my

proposal for insurance(s) and that failure to disclose any material fact known to me may invalidate my insurance(s) .

Page 1 of 1
24-07-2021 01:24:06
 e-KYC DETAILS FROM UIDAI

Access Id : 989073245

▼ Personal Details

Aadhaar No. / Virtual ID : ********9077

Name :` Suraj Pratap Singh Photo

08-11-2000
Date of Birth : Gender : M

▼ Contact Details

C/o.

House / Bldg. / Apt. J-307 /2

Awas Vikas No-1

Street / Road / Lane

Landmark

Keshav Puram
Area / Locality / Sector

208017
Pincode

Village / Town / City Kanpur

Kanpur
P.O.

Kanpur Nagar
District

Uttar Pradesh
State

Page 1 of 1