Proposal Form

Plan Details

Plan Name Plan No

Jeevan Labh 936

Proposal Date * UIN

04-08-2024 512N304V02
Agency Code Supervisor Code Branch Code
0189326A 260099 26A

Access Id Email Id Mobile No.

2450534668 shuklaavnish33@[Link] 7525024242
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

* Date of Proposal - Pertains to date when customer verified the proposal. Proposal number is
allotted only after receipt of the full proposal-deposit amount by LIC

Details of plan proposed

Term & PPT Sum Assured Installment Premium GST

21 - 15 ₹ 2,00,000 ₹ 934 ₹ 84
Total Amount Mode of Payment Date of
₹ 1,952 Monthly Commencement **
28-07-2024

AB/ADDB Req AB/ADDB Sum Assured

ADDB REQUIRED ₹ 2,00,000
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 Yes No
paramilitary force?
If "Yes", (ii). Whether you wish to avail the AB/AD& DB rider while on police duty? Yes No

** Date of Commencement - This date is tentative Date of Commencement , subject to change

based on date of payment and underwriting.

Personal details of the life to be insured

Name
AVANISH
Father's Name Mother's Name
Mr SANJEEV SHUKLA Mrs MAMTA
Gender
Male Female Third Gender

Martial Status Spouse Name Date of birth

Married Shivani 13-07-1996
Age (in years) Place of birth Residential Status Citizenship
28 Years Bela Resident Indian Indian
 Communication details of the life to be insured

Present Address for communication

Address Line 1 Address Line 2
SANJEEV KUMAR SHUKLA H N 80 BELA UTTAR PRADESH
BELA AURAIYA
Address Line 3 City District
. Auraiya Auraiya
State Country Pin Code
UP IN 206251
Permanent Residential Address
Address Line 1 Address Line 2
SANJEEV KUMAR SHUKLA H N 80 BELA UTTAR PRADESH
BELA AURAIYA
Address Line 3 City District
. Auraiya Auraiya
State Country Pin Code
UP IN 206251

KYC Particulars

Are you an It Assessee Yes No

PAN Proof of Identity Address Proof Central Kyc

RegistryNo
BNOPA6121N ckyc ckyc 30038798834905

Nature of age proof

submitted
ckyc
Are you (Proposer) registered under the GST act ? Yes No

Occupation Details

Present Occupation Exact Nature of duties Name of the present

employer
Agriculture Business
Annual income source of income Education Purpose of insurance
Qualification
₹ 2,00,000 Self Employed Post Graduate or Risk Coverage
Graduate with savings
 Tax Residency Details

Is your country of Tax Residency outside India ? Yes No

Other Personal Details

Is your occupation associated with any specific hazard or do you take part in hazardous Yes No
activities or have hobbies that could be dangerous in any way?
Are you Politically Exposed Person (PEP) OR are you a family member or close relative of Yes No
PEP ? (As per RBI guidelines PEPs are the individuals who are or have entrusted with
prominent public functions in a foreign country.)
Have you ever been or are currently being investigated, charge sheeted, prosecuted or Yes No
convicted or having pending charges in respect of any criminal/civil offences in any court
of law in India or abroad ?

Lifestyle Details

Do you smoke / Yes/No If YES, Quantity If STOPPED, Since

consume or have you consumed and how may months
ever smoked / Duration
consumed the
following

Alcoholic drinks Yes No

Narcotics Yes No

Any other drugs Yes No

Do you smoke/consume Yes No

or have you
smoked/consumed
tobacco in any form (
cigars, cigarettes,
beedis, pan masala etc)
in the past 60 months.
(in sticks /packets/
sachets/gms per day)
 Details of previous policies held / proposals applied of the life to be
insured

a) Is your life now being proposed for another assurance or an application for revival of a Yes No
policy on your life or any other proposal under consideration in any office of Life
Insurance Corporation of India or to any other insurer?
b) Whether proposed simultaneously on the life of spouse and children ? Yes No

c) 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:
c.1) Withdrawn, Deferred, Dropped or Declined? Yes No

c.2) Accepted with extra Premium or Lien? Yes No

c.3) Accepted on terms otherwise than those proposed? Yes No

c.4) Have you during past one year returned any policy of Life Insurance Yes No
Corporation of India as the same was not acceptable to you?

I hereby declare that I do not have any existing policies in-force or lapsed policies with LIC.

I hereby declare that I do not have any existing policies in force or lapsed policies with other Insurers.
 Medical details of the life to be insured

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
1. Lungs/Respiratory disease/Persistent cough, asthma, bronchitis, pneumonia, spitting Yes No
of blood etc.
2. Hypertension, Hypotension, rheumatic fever, pain in chest, breathlessness, Yes No
palpitation, any disease of the heart or arteries
3. Peptic ulcer/colitis, jaundice, anaemia, piles, dysentery, or any other disease of the Yes No
stomach, liver, spleen, gall bladder or pancreas/digestive disorder
4. Any disease of kidney/prostate or urinary system Yes No

5. Paralysis/epilepsy/insanity/tremors, numbness, double vision, dizzy or fainting Yes No

spells/head injury / insomnia /nervous breakdown/any other disease of the brain or the
nervous system
6. Hernia/hydrocele, varicocele, fistula, varicose veins, filariasis, gonorrhoea, syphilis or Yes No
any other veneral disease
7. Cancer/leukemia/lymphoma/tumour/cyst/ any other growth/lumps/blood Yes No
disorder/enlarged glands.
8. Any disease of ear, nose, throat or eyes, including defective sight or hearing and Yes No
discharge from the ears
9. Endocrine disorders such as Diabetes, Goitre, Thyroid etc or have you ever passed Yes No
sugar, albumin, pus or blood in urine
10. Bone / Joint / Spine disease / Arthritis Yes No

11. Mental Disorder (Depression/Anxiety etc) Yes No

12. Chronic infections - Tuberculosis/pleurisy/skin disease/skin eruption/leprosy Yes No

13. Hepatitis or AIDS & HIV related condition Yes No

14. Any operation, accident or injury/any bodily defect or deformity

None
15. Any other disease ? Yes No
 Medical History of the life to be insured

Height (in cms) Weight (in Kgs)

158 60

What has been your usual state of health? Good Not

Good

During the last five years did you consult a Medical Practitioner for any Yes No
ailment requiring treatment for more than a week ?
Have you ever been admitted to any hospital or nursing home for general Yes No
check up, observation, treatment or operation?
Have you remained absent from place of work on grounds of health during the Yes No
last 5 years ?
 Family Medical history

Have your parents / spouse / partner / children and/or any of your relations ever suffered Yes No
from or died of 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.?

Family History

Relationship Living/Dead Present age State of Age of Death Cause of

Health Death

Father Living 56 Good NA NA

Mother Living 52 Good NA NA

Brother Living 30 Good NA NA

Daughter Living 32 Good NA NA

Daughter Living 25 Good NA NA

Spouse Living 24 Good NA NA

Son Living 1 Good NA NA

 Bank details of Proposer

Your bank account type Savings Current

Account Number IFSC Code Bank Name

237601507189 ICIC0002376 ICICI BANK LIMITED

Bank Address
VIBHAVKHAND

Nach Details
Your bank account type Savings Current

Account Number IFSC Code Bank Name

237601507189 ICIC0002376 ICICI BANK LIMITED
Bank Address
VIBHAVKHAND

Settlement Option

Do you Wish to avail Option for Maturity Benefit in installments Yes No

Do you Wish to avail Option for Death Benefit in installments Yes No

Nomination Details

Particulars of Nomination

SI No. name of the Nominee Age Relationship to the life assured Share(%)

1 Shivani 24 Wife 100

 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.
(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
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.
Signature of the life to be
Assured
 Declaration of the life to be insured

I AVANISH 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 above 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
premium and benefits under the policy are subject to taxes / duties/ charges in accordance with the laws as
applicable from time to time.
Signature of the Life
to be insured

Name Address Pin Code

AVANISH SANJEEV KUMAR SHUKLA H N 80 BELA 206251
BELA AURAIYA UTTAR PRADESH Auraiya
UP
 Suitability Analysis

Proposer Full Name Date of Birth

AVANISH 13-07-1996

Age Maritial Status Occupation

28 Years Married Agriculture

Address
SANJEEV KUMAR SHUKLA H N 80 BELA BELA AURAIYA UTTAR PRADESH Auraiya
206251

2. What is proposer'yearly income from: (if life assured is different from the proposer)
Employment Businees / Profession Other Sources H.U.F. if any
₹ ₹ 2,00,000

Income of life to be
assured
₹ 2,00,000

3. Whether income proof submitted? (if Yes, give details below)

Nature of document Is he/she Income tax Is yes, please provide Income Tax Bracket
for income verification Assessee PAN 0%
Yes BNOPA6121N

4. Previous Policy Details (as per proposal form)

5. Family History (as per proposal form)
Spouse Details
Name Occupation Annual Income
NA NA NA

6. Need Analysis
Total Annual Income
₹ 2,00,000

Outstanding Liablities
Secured Loans Non-Secured Loans

based on his age and income, the maximum insurance that can be granted is:
Age Group Multiple of Avg. Maximum allowable
Annual Income Insurance

7.
Object of Insurance How would you like to pay your premiums
Risk Coverage with savings Monthly

Risk Profile Time frame for this invesement

Conservative to Moderate
8. Categorization of plans in relation to object of Insurance
Category Risk Profile Plan Name
Conservative to Conservative to Jeevan Labh
Moderate Moderate
9. Product Chosen
Plan No Plan Name Term Sum Assured
936 Jeevan Labh 21 ₹
2,00,000

Mode Premium
Monthly ₹ 934

a) if ULIP is proposed:
1st Year 2nd Year 3rd Year onwards Life cover
charges

Policy Administration Fund Management

Charges Charges

b) if Annuity / Pension is proposed:

Target Annuity per annum Type of Annuity Annuity Amount per Defement
annum Period

Is the total insurance added to the present proposal is reasonable in relation to income
The questions above pertain to your personal condition at the time of appliction 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.
I AVANISH , having received the informationwith respect to the above, have understood the selection of
product befor into this contract. My plan details are as following:
Plan No Plan Name Term Sum Assured
936 Jeevan Labh 21 ₹
2,00,000

Mode Premium
Monthly ₹ 1,952

KYC Details as per CKYC

Personal Details
Aadhaar No. / Virtual ID
********9629

Name Date of Birth

Mr AVANISH 13-07-1996
Gender
Male

Contact Details
C/o. House/ Bldg. / Apt.

Steert/ Road/ Lane Landmark

SANJEEV KUMAR SHUKLA H N 80 BELA UTTAR PRADESH
BELA AURAIYA

Area/ Locality/ Sector Pincode

206251

Village/ Town/ City P.O.

Auraiya
District State
Auraiya UP
 LIC's Jeevan Labh (Plan No. 936)

Benefit Illustration

LIC's Jeevan Labh (Plan No. 936)

A Non-Linked, Participating, Individual, Life Assurance Savings Plan
(Unique Identification Number - 512N304V02)

Distribution channel Offline Agency name SMT. NEELAM TIWARI Agency code 0189326A
Name of Age of
Avanish 28 years Date of illustration 28-07-2024
prospect/policyholder prospect/policyholder
Name of life assured Avanish Age of life assured 28 years Benefit UID/Proposal no.
Mode of payment of
Policy term 21 years Premium payment term 15 years Monthly
premium
Sum assured on death Instalment premium
Basic sum assured Rs. 2,00,000 2,00,000 913.00
(at inception of the policy) Rs. (for base plan)

Bonus type Simple reversionary and final additional bonus

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.

Premium summary
Particular Base plan Riders1 Total instalment premium
Instalment premium without GST 913.00 922.00
Instalment premium with GST @ 4.50% (1st year) 954.00 963.00
Instalment premium with GST @ 2.25% (2nd year onwards) 933.54 942.75
GST rate shall be as applicable from time to time

Page 1
 LIC's Jeevan Labh (Plan No. 936)

(Amount in rupees)

Total benefits (including guaranteed and non-guaranteed benefits)

Non-guaranteed benefits Non-guaranteed benefits
Guaranteed benefits @ 4% p.a. @ 8% p.a.
Maturity benefit Death benefit3 Surrender benefit4
Annualized Maturity Maturity Death Death
Policy year premium2 benefit, incl. benefit, incl. benefit, incl. benefit, incl.
(cumulative) of final of final of final of final Surrender Surrender
Surrender Death Maturity Reversionar Surrender Reversionar Surrender additional additional additional additional benefit @ benefit @
benefit benefit benefit y bonus benefit y bonus benefit bonus bonus bonus bonus 4% (3+7) 8% (3+9)
(FAB), if (FAB), if (FAB), if (FAB), if
any, @ 4% any, @ 8% 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 10741 0 200000 0 800 0 6000 0 0 0 200800 206000 0 0

2 21482 6445 200000 0 1600 0 12000 0 0 0 201600 212000 6445 6445

3 32223 11278 200000 0 2400 382 18000 2867 0 0 202400 218000 11660 14145

4 42964 21482 200000 0 3200 519 24000 3893 0 0 203200 224000 22001 25375

5 53705 26853 200000 0 4000 663 30000 4974 0 0 204000 230000 27516 31827

6 64446 32223 200000 0 4800 817 36000 6131 0 0 204800 236000 33040 38354

7 75187 37594 200000 0 5600 984 42000 7384 0 0 205600 242000 38578 44978

8 85928 44940 200000 0 6400 1125 48000 8438 0 0 206400 248000 46065 53378

9 96669 52781 200000 0 7200 1272 54000 9536 0 0 207200 254000 54053 62317

10 107410 61116 200000 0 8000 1428 60000 10710 0 0 208000 260000 62544 71826

11 118151 69945 200000 0 8800 1598 66000 11986 0 0 208800 266000 71543 81931

12 128892 79269 200000 0 9600 1786 72000 13392 0 0 209600 272000 81055 92661

13 139633 89086 200000 0 10400 1995 78000 14960 0 0 210400 278000 91081 104046

14 150374 99548 200000 0 11200 2232 84000 16741 0 0 211200 284000 101780 116289

15 161115 110364 200000 0 12000 2502 90000 18765 0 0 212000 291000 112866 129129

16 161115 114069 200000 0 12800 2815 96000 21110 0 0 212800 297000 116884 135179

17 161115 117775 200000 0 13600 3180 102000 23848 0 0 213600 304000 120955 141623

18 161115 121481 200000 0 14400 3607 108000 27054 0 0 214400 311000 125088 148535

19 161115 125186 200000 0 15200 4113 114000 30848 0 0 215200 318000 129299 156034

20 161115 145004 200000 0 16000 4800 120000 36000 0 0 216000 325000 149804 181004

21 161115 145004 200000 200000 16800 5880 126000 44100 216800 332000 216800 332000 150884 189104

Page 2
 LIC's Jeevan Labh (Plan No. 936)

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), having received

I, ________________________________________ (name), have explained the information with respect to the above, have understood the above statement
the premiums and benefits under the product fully to the prospect/policyholder. before entering into the contract.
Place : Place :
Date : Signature of agent/intermediary/official Date : Signature of prospect/policyholder

Page 3