Proposal Form

Plan Details

Plan Name Plan No

LIC’s Jeevan 736
Labh

UIN
512N304V03
Agency Code Supervisor Code Branch Code
0166043A 9999999 43A

Access Id Email Id Mobile No.

2551449603 midya.dinesh30@[Link] 9674022373
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 ₹ 1,081 ₹ 147
Total Amount Mode of Payment Date of
₹ 3,390 Monthly Commencement **
09-08-2025
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
Dinesh Kumar Midya
Father's Name Mother's Name
AMRITA RANJAN MIDYA PUSPA RANI MIDYA

Gender
Male Female Third Gender
Martial Status Date of birth ABHA number
Single 20-03-1980
Age (in years) Residential Status
45 Years Resident Indian
Do you wish to avail the physical policy document? Yes No

please give EIA no. (e-Insurance Account) if available

Is the Tax Residency outside India? Yes No

Employer-Employee Scheme/KMI/HUF

Whether proposal is under Employer-Employee

No
Scheme/KMI/HUF ?
 Communication details of the life to be insured

Present Address for communication

Address Line 1 Address Line 2
, , , , , Usman Chak, Purba Medinipur, West Bengal
Address Line 3 City District
Purba Medinipur
State Country Pin Code
West Bengal India 721631
Permanent Residential Address
Address Line 1 Address Line 2
, , , , , Usman Chak, Purba Medinipur, West Bengal
Address Line 3 City District
Purba Medinipur
State Country Pin Code
West Bengal India 721631

KYC Particulars

Are you an It Assessee Yes No

PAN Proof of Identity Age proof submitted

AOXPM6072R ekyc ekyc

If Registered under GST Yes No

Occupation Details

Present Occupation Exact Nature of duties Name of the present Length of service
employer
Teacher having Service TENTULBERIA 14 Years
[Link]. NEW SETUP 00 Months
UPPER PRIMARY
SCHOOL
Annual income source of income Education Purpose of insurance
Qualification
₹ 8,00,000 Employed Post Graduate or Risk Coverage
(Salary) Graduate with savings
Are you employed in the Armed Forces Yes No
 Other Personal Details of the life to be insured

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 of the life to be insured

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

Has a proposal ( or an application for revival of a policy) on your life made to any office of the
Corporation or to any other Insurer ever been Accepted with extra or modified terms, Withdrawn,
Deferred, Dropped or Declined?, if yes give proposal number& branch / policy number / Name of
Insurer Yes No

Have you during the past one year returned any policy of the Corporation as the same was not
acceptable to you?, if yes give policy number. Yes No

LIC Previous Policies

Policy No Plan Policy Paying Summassured Premium Term of Date of

No Term Term Mode Acceptance Commencement

438546314 133 20 20 ₹ 1,00,000 NA 28-04-2007

Other Inusrer Previous Policies

Policy No Insurer Summassured Insured Type

U202964449 TATA AIA Life Insurance Co Ltd ₹ 3,60,000 NONLIC

 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, Yes No
Tuberculosis/, pleurisy / spitting of blood/Covid 19etc
2. Peptic ulcer/colitis, jaundice,Hepatitis, anaemia, piles, dysentery, or any other disease Yes No
of the stomach, liver, spleen, gall bladder or pancreas/ digestive disorder
[Link], Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, Yes No
any disease of the heart or arteries?
4. Endocrine disorders such as Diabetes, Goitre, Thyroid etc or have you ever passed Yes No
sugar, albumin, pus or blood in urine
5. Any disease of kidney /prostate or urinary system? Yes No

6. Bone / Joint/ Spine Disease/ Arthritis / varicose veins /any bodily defect or deformity Yes No

7. Any disease of ear, nose, throat or eyes, including defective sight or hearing and Yes No
discharge from the ears
8. Cancer/leukemia/lymphoma/ tumour / cyst/ Any other growth / lumps/ blood disorder Yes No
/enlarged glands
[Link]/epilepsy/ insanity/ tremors, numbness, double vision, dizzy or fainting spells/ Yes No
head Injury / insomnia/ nervous breakdown / Mental Disorder (Depression/ Anxiety, etc.).
/ any other disease of the brain or the nervous system
10. Chronic infections- Skin Disease/ skin eruption/ Leprosy / ,filariasis, gonorrhoea, Yes No
syphilis or any other venereal disease or AIDS&HIV related condition
11. Hernia/hydrocele, varicocele, fistula Yes No

12. Any other disease ? Yes No

 Medical History of the life to be insured

Please state exact height and weight ( without shoes)

Height (in cms) Weight (in Kgs)
169 69

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 History

(Please mention specifically if suffering 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)

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

Health Death

Father Dead NA NA 75 Old age

Mother Living 85 Good NA NA

 Bank details of the life to be insured

Your bank account type Savings Current

Account Number IFSC Code Bank Name

11079928617 SBIN0011531 STATE BANK OF INDIA

Nach Details
Your bank account type Savings Current

Account Number IFSC Code Bank Name

397902010108562 UBIN0539791 UNION BANK OF INDIA

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 Age Relationship Address of

the to the life Nominee Share(%)
Nominee assured
1 PUSPA 85 Mother , , , , , Usman 100
RANI Chak, Purba
MIDYA Medinipur,,West
Bengal,,, 721631

Mobile Email Bank Name Account No

Number IFSC Code
 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 sommencement 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 Dinesh Kumar Midya 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 ofprivacy, 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 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 am
aware that if the information on my Tax Residency is found to be false or untrue or misleading or
misrepresenting, I may be held liable for it. I also undertake to inform the Corporation of any change in my Tax
Residency status. I undertake to inform the Corporation immediately of any changes in KYC documents such as
residence. I also give my consent to obtain and share my data from / with Central KYC Registry respectively 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/whatsapp messages, E mail on the above mentioned
registered number(s)/ E mail address from / on behalf of the Corporation with respect to my life insurance
policy/regarding servicing of insurance policies/ notifying about the status of Claim 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

Dinesh Kumar , , , , , Usman Chak, Purba Medinipur, 721631
Midya West Bengal Purba Medinipur West
Bengal
 Suitability Analysis

Proposer Full Name Date of Birth

Dinesh Kumar Midya 20-03-1980

Age Maritial Status Occupation

45 Years Single Teacher having [Link].

Address
, , , , , Usman Chak, Purba Medinipur, West Bengal 721631
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
₹ 8,00,000 ₹ 0 ₹ 0 ₹ 0
Income of life to be
assured
₹ 0

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 10%
Yes AOXPM6072R

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
₹ 8,00,000
Outstanding Liablities
Secured Loans Non-Secured Loans
₹ 0 ₹ 0

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 LIC’s Jeevan Labh
Moderate Moderate
9. Product Chosen
Plan No Plan Name Term Sum Assured
736 LIC’s Jeevan Labh 21 ₹
2,00,000

Mode Premium
Monthly ₹ 1,081

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 Dinesh Kumar Midya, 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
736 LIC’s Jeevan Labh 21 ₹
2,00,000

Mode Premium
Monthly ₹ 3,390

KYC Details as per E-KYC

Personal Details
Pan No
AOXPM6072R

Name Date of Birth

Dinesh Kumar Midya 20-03-1980
Gender
Male

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

Steert/ Road/ Lane Landmark

, , , , , Usman Chak, Purba Medinipur, West Bengal

Area/ Locality/ Sector Pincode

721631
Village/ Town/ City P.O.

District State
Purba Medinipur West Bengal
 CUSTOMER INFORMATION SHEET /KNOW YOUR POLICY

This document provides key information about your policy. You are also advised to go through your
Policy Document.

Name of the Insurance Product And Unique Identification Number (UIN)

LIC’s Jeevan Labh (UIN: 512N304V03) Part A

Policy Number
Part A

Type of Insurance Policy

Non-Linked other than Pure risk and pension Part B - Definitions

Basic Policy details

Instalment Premium (Rs): ₹ 1,081 (Taxes, if any, as applicable from time to Schedule
time are charged extra).
Mode of Premium Payment: Monthly Schedule
Premium Payment Term: 15 Schedule
Policy Term: 21 Schedule
Basic Sum Assured (Rs): ₹ 2,00,000 Schedule
Sum Assured on Death: Sum Assured on Death is defined as Higher of Basic Condition 1.A of Part C
Sum Assured or 7 times of Annualized Premium
Sum Assured on Maturity: Sum Assured on Maturity is equal to Basic Sum Condition 1.B of Part C
Assured.

Riders opted, if any

Not Applicable (if rider is not opted) Rider Name and UIN (as opted for by the Schedule
policyholder) For details of Benefits and Conditions of riders(s), mentioned above,
refer Endorsement to this policy.

Policy Coverage / benefits payable

Benefit payable on Death: Death benefit payable in case of death of the Life Condition 1.A of Part C
Assured before the stipulated Date of Maturity provided the policy is in​force shall
be “Sum Assured on Death” along with vested Simple Reversionary Bonuses and
Final Additional Bonus, if any.

This Death Benefit shall not be less than 105% of total premiums paid upto the
date of death.
Benefit payable on Maturity: On Life Assured surviving the stipulated Date of Condition 1.B of Part C
Maturity provided the policy is in-force, “Sum Assured on Maturity” along with
vested Simple Reversionary Bonuses and Final Additional Bonus, if any, shall be
payable. any.
Surrender Benefit: The policy can be surrendered by the policyholder after Condition 4 of Part D
completion of first policy year provided one full year’s premium(s) has been paid.
However, the policy shall acquire Guaranteed Surrender Value on payment of
atleast two full years’ premiums and Special Surrender Value after completion of
first policy year provided one full year’s premium(s) has been paid. On surrender of
an in-force or paid-up policy, the Corporation shall pay the Surrender Value equal
to higher of Guaranteed Surrender Value and Special Surrender Value
Options to Policyholders for availing benefits, if any, covered under the
policy: Condition 8 of Part D

i) Option to take Death Benefit in instalments: This is an option to receive

Death Benefit in instalments over the chosen period of 5 or 10 or 15
years instead of lump sum amount under an in-force as well as paid-up
policy.
ii) Settlement Option (for Maturity Benefit): Settlement Option is an Condition 8 of Part D
option to receive Maturity Benefit in instalments over the chosen period
of 5 or 10 or 15 years instead of lumpsum amount under an in-force as
well as paid-up policy.

Options available (in case of Linked Insurance Products)

Not Applicable

Option available (in case of Annuity product)

Not Applicable

Exclusions (events where insurance coverage is not payable), if any.

Suicide Exclusion: The provisions related to claim payment in case of death due Condition 2 of Part Fx
to suicide shall be subject to the conditions as specified herein under:

i) If the Life Assured (whether sane or insane) commits suicide at any time within
12 months from the date of commencement of risk, the Nominee or Beneficiary of
the Life Assured shall be entitled to 80% of the total premiums paid till the date of
death (excluding any extra premium, rider premiums other than term assurance
rider, if any and taxes, if collected explicitly), provided the policy is in force.

ii) If the Life Assured (whether sane or insane) commits suicide within 12 months
from date of revival, an amount which is higher of 80% of the total premiums paid
till the date of death (excluding any taxes if collected explicitly, extra premium and
rider premiums other than term assurance rider, if any,) or the surrender value
available as on the date of death, shall be payable. The Nominee or Beneficiary of
the Life assured shall not be entitled to any other claim under this policy.

Waiting/ lien Period, if any

Not Applicable

Grace period

30 Days for Yearly, Half-yearly, Quarterly mode of premium payment Condition 6 of Part C
15 Days for Monthly mode of premium payment

Free Look Period

30 Days Condition 7 of Part D
Lapse, paid-up and revival of the Policy

Lapse: Lapse is the status of the policy when due premium is not paid Part B-Definitions
within the days of grace.
Paid-Up: If after at least one full year’s premium(s) has been paid and condition 2 of Part D
any subsequent premiums be not duly paid, on completion of first policy
year, this policy shall not be wholly void, but shall subsist as a paid-up
policy till the end of the policy term.
Revival: A policy in lapsed condition may be revived during the life time Condition 3 of Part D
of the Life Assured, but within the Revival Period and before the date of
maturity, as the case may be.

Policy Loan, if applicable

Loan can be availed after completion of first policy year, provided one full year’s Condition 5 of Part D
premium(s) has been paid and shall be subject to the terms and conditions of the
policy

Claims/ Claims Procedure

 Turn Around Time (TAT) for claims settlement and brief procedure: Condition 4 of Part F

S Bench
Description of Service
No Marks
1 Maturity claim/Survival Benefit/Annuity/Pension On or
processing subject to receipt of all documents before due
date
2 Raising claim requirements after lodging the claim 15 days
3 Death Claim Payment/Rejection/Repudiation without 30 days
investigation requirement under a Life Policy
4 Death Claim Payment/Rejection/Repudiation with 120 days
investigation requirement under a Life Policy

Helpline/Call Centre number: 91-022-68276827 SMS LICHELP TO

9222492224 Whatsapp No.: 8976862090

Contact details of the insurer: You may contact us at our Branch

Office the details of which are mentioned in the Part A (First page) of the
Policy Document. Alternatively the Branch Locator can be found on the
below link: [Link]

Link for downloading claim form and list of documents required

including bank account details: [Link]
forms
List of documents required:

1. Claim forms, as prescribed by the Corporation

2. Policy Document

3. NEFT mandate

4. Proof of title

5. Proof of death

6. Medical treatment prior to the death (if any)

7. school/college/employer’s certificate, whichever is applicable

8. Proof of age of the Life Assured, if the age is not admitted under the
policy, shall also be submitted

9. First Information Report (FIR), Panchnama and Post Mortem report

where applicable

10. Any other additional documents as may be required by the

Corporation
For updated details, we request you to regularly check our website [Link]

Policy Servicing
 Turn Around Time (TAT):

S
Description of Service Bench Marks
No
1 Free look cancellation/ surrender/ Withdrawal/ 15 days
Request for refund of proposal deposit/Refund of
outstanding proposal deposit subject to receipt of
all documents
2 Raising claim requirements after lodging the claim 15 days
3 Issuance of policy document after acceptance of 5 days
the proposal
4 Registration of nomination/ Assignment/ Re- 3 days
assignment and return of policy document
5 Effecting revival/ alteration/ issue of duplicate 2 days
policy on receipt of all requirements
6 Loan Settlement after receipt of all requirements 3 days
7 Intimation of status of SSS policies Once a year
along with
Bonus
informa tion

8 Effecting change of address/ transfer In-Out and Same day

other enquiries under the policies
9 Acknowledge a grievance 3 days
10 Resolve a grievance 15 days

Helpline/Call Centre number: 91-022-68276827 SMS LICHELP TO

9222492224 Whatsapp No.: 8976862090

Contact details of the insurer: You may contact us at our Branch

Office the details of which are mentioned in the Part A (First page) of the
Policy Document.

Alternatively the Branch Locator can be found on the below link:

[Link]

Link for downloading applicable forms and list of documents required

including bank account details: [Link]
forms

For updated details, we request you to regularly check our website

[Link]

Grievances /Complaints
Contact details of Grievance Redressal Officer of the insurer:
You may contact the Grievance Redressal Officer on the address as
mentioned in the Part A (First page) of the Policy Document.

Alternatively the details of Grievance Redressal Officers can be found on

the below link: [Link]
Link for registering the grievance with the insurer’s portal: If you
are a registered policy holder you can directly register complaint/
grievance and track its status through our Customer Portal (website)
[Link] You can also contact at e-mail id
co_complaints@[Link] for redressal of any grievances.

Link for registering: [Link]

2703123.1272923387.1677050657- 120722208.1677050657#Login
Contact details of Ombudsman: You can also approach Insurance
Ombudsman whose Address and contact details is given in Part A (First
page) of the Policy Document.

Alternatively the details of Ombudsman can be found on the below link:

[Link]

Contact No. 022-69038800/69038812

Declaration by the Policyholder

I have read the above and confirm having noted the details.

Place:(Signature of the Policyholder)

Note:

i. Product related documents including the Customer Information sheet are available on
Corporation’s website [Link]

[Link] case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
 LIC's Jeevan Labh (Plan No. 736)

Benefit Illustration

LIC's Jeevan Labh (Plan No. 736)

A Par, Non-Linked, Life, Individual Savings Plan
(Unique Identification Number - 512N304V03)

Distribution channel Offline Agency name PRASAD KUMAR MIDYA Agency code 0166043A
Name of Age of
DINESH KUMAR MIDYA 45 years Date of illustration 09-08-2025
prospect/policyholder prospect/policyholder
Name of life assured DINESH KUMAR MIDYA Age of life assured 45 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 1,060.00
(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 1,060.00 21.00 1,081.00
Instalment premium with GST @ 4.50% (1st year) 1,108.00 22.00 1,130.00
Instalment premium with GST @ 2.25% (2nd year onwards) 1,083.85 21.47 1,105.32
GST rate shall be as applicable from time to time.

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 LIC's Jeevan Labh (Plan No. 736)

(Amount in rupees)
Total benefits (including guaranteed and non-
guaranteed benefits)
Guaranteed benefits Non-guaranteed benefits @ 4% p.a. Non-guaranteed benefits @ 8% p.a.
Maturity benefit Death benefit4
Annualize Maturity Death
Policy Maturity Death
d benefit, benefit,
year (End premium benefit, benefit,
2 incl. of incl. of
of the Total Total incl. of incl. of
(cumulativ Guarantee guarantee Special guarantee Special final final final final
year) d Death Maturity Reversion Surrender Reversion Surrender additional additional additional additional
e) d surrender d surrender
surrender benefit benefit ary bonus surrender benefit ary bonus surrender benefit bonus bonus
value3 value3 bonus bonus
value (FAB), if (FAB), if
value3 value3 (FAB), if any, (FAB), if
@ 8% any, @ 4% any, @ 8%
any, @ 4%
(5+6+FAB) (5+10+FA (4+6+FAB) (4+10+FA
B) B)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

1 12466 0 200000 0 800 0 3195 3195 6000 0 3195 3195 0 0 200800 206000

2 24932 7632 200000 0 1600 7632 6853 7632 12000 7632 6853 7632 0 0 201600 212000

3 37398 13356 200000 0 2400 13738 11685 13738 18000 16223 15985 16223 0 0 202400 218000

4 49864 25440 200000 0 3200 25959 16717 25959 24000 29333 22867 29333 0 0 203200 224000

5 62330 31800 200000 0 4000 32463 22423 32463 30000 36774 30672 36774 0 0 204000 230000

6 74796 38160 200000 0 4800 38977 28874 38977 36000 44291 39498 44291 0 0 204800 236000

7 87262 44520 200000 0 5600 45504 36150 45504 42000 51904 49451 51904 0 0 205600 242000

8 99728 53220 200000 0 6400 54345 44345 54345 48000 61658 60660 61658 0 0 206400 248000

9 112194 62506 200000 0 7200 63778 53551 63778 54000 72042 73254 73254 0 0 207200 254000

10 124660 72377 200000 0 8000 73805 63883 73805 60000 83087 87387 87387 0 0 208000 260000

11 137126 82833 200000 0 8800 84431 75432 84431 66000 94819 103186 103186 0 0 208800 266000

12 149592 93874 200000 0 9600 95660 88379 95660 72000 107266 120895 120895 0 0 209600 272000

13 162058 105500 200000 0 10400 107495 102817 107495 78000 120460 140646 140646 0 0 210400 278000

14 174524 117889 200000 0 11200 120121 118938 120121 84000 134630 162698 162698 0 0 211200 284000

15 186990 130698 200000 0 12000 133200 136888 136888 90000 149463 187253 187253 0 0 212000 291000

16 186990 135086 200000 0 12800 137901 147662 147662 96000 156196 205394 205394 0 0 212800 297000

17 186990 139475 200000 0 13600 142655 159303 159303 102000 163323 225232 225232 0 0 213600 304000

18 186990 143863 200000 0 14400 147470 171970 171970 108000 170917 247047 247047 0 0 214400 311000

19 186990 148252 200000 0 15200 152365 185675 185675 114000 179100 270919 270919 0 0 215200 318000

20 186990 171720 200000 0 16000 176520 200578 200578 120000 207720 297152 297152 0 0 216000 325000

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 LIC's Jeevan Labh (Plan No. 736)

(Amount in rupees)
Total benefits (including guaranteed and non-
guaranteed benefits)
Guaranteed benefits Non-guaranteed benefits @ 4% p.a. Non-guaranteed benefits @ 8% p.a.
Maturity benefit Death benefit4
Annualize Maturity Death
Policy Maturity Death
d benefit, benefit,
year (End premium benefit, benefit,
2 incl. of incl. of
of the Total Total incl. of incl. of
(cumulativ Guarantee guarantee Special guarantee Special final final final final
year) d Death Maturity Reversion Surrender Reversion Surrender additional additional additional additional
e) d surrender d surrender
surrender benefit benefit ary bonus surrender benefit ary bonus surrender benefit bonus bonus
value3 value3 bonus bonus
value (FAB), if (FAB), if
value3 value3 (FAB), if any, (FAB), if
@ 8% any, @ 4% any, @ 8%
any, @ 4%
(5+6+FAB) (5+10+FA (4+6+FAB) (4+10+FA
B) B)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

21 186990 171720 200000 200000 16800 177600 216800 216800 126000 215820 332000 332000 216800 332000 216800 332000

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. Surrender value is higher of guaranteed surrender value (GSV) and special surrender value (SSV). SSV shall be reviewed in line with IRDAI Master Circular on Life
Insurance Products (Ref no.: IRDAI/ACTL/MSTCIR/MISC/89/6/2024 dated 12th June, 2024) and any subsequent circulars issued by IRDAI in this regard. For surrender
value calculation, it is assumed that the bonuses shall vest upon its declaration based on experience of the Corporation under this product, in the manner as per the terms
and conditions of annual valuation results.
4. In any case, the total death benefit during the policy term shall not be less than 105% of the total premiums paid (excluding GST, extra premium and rider premiums, if
any).
5. The actual allocation to policyholders, out of the surplus emerging from the actuarial investigation, shall be in accordance with provisions in this regard under LIC Act, 1956.

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 of the insurer Date : Signature of prospect/policyholder

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