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PLI Self Declaration Form Template

This document is a self-declaration form for a Postal Life Insurance Policy, where the individual provides personal details including their name, age, date of birth, employment information, and income. The individual confirms the accuracy of the information provided and encloses supporting documents. The declaration is signed and dated by the insurant and includes an income declaration statement related to their profession.

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bpmpochampalli
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271 views1 page

PLI Self Declaration Form Template

This document is a self-declaration form for a Postal Life Insurance Policy, where the individual provides personal details including their name, age, date of birth, employment information, and income. The individual confirms the accuracy of the information provided and encloses supporting documents. The declaration is signed and dated by the insurant and includes an income declaration statement related to their profession.

Uploaded by

bpmpochampalli
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SELF DECLARATION

In r/o Postal Life Insurance Policy – Extended Clientele)

I……………………………………………………………………….aged……………………years S/O/ D/O/ W/o………….

do hereby declare that

(a) My date of birth as per school record is……………………………………(in figures)……………………………….

(b) I am working as ……………………………………………………..in………………………………………………organization


since …………………………………and my Employee ID No. is ………………………………………………………

(c) I am enclosing the following documents in support of my proposal

(i) (ii)

(ii) (iv)

Further, I state that what are all above furnished by me is true and correct to the best of my

personnel knowledge, information and belief and I signed on this self declaration on this ………………day

of ………………….year……………………….at ……………………………

Place:

Date: signature of the insurant.

INCOME DECLRATION

I …………………………………………………………………………….s/o …………………………………………….aged
about……….years, hereby declare that the following statement is true to the best of my knowledge. I
am furnishing the following statement as required by your Department to take Postal Life Insurance
Policy.

I am doing my profession in support with my…………………………Degree and I am earning an


amount of Rs……………………….per month towards my profession.

Attestation f F.O. Signature of the proponent.

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