Lic Form 300 – Fill Out and Use This PDF

	Life Insurance Corporation of India			FORM NO.300(Rev 02)
			FORM NO. 300 (Rev. 02 )F300v1.0 ID.No :1105122410
			PROPOSAL FOR INSURANCE ON OWN LIFE
			(Not to be used on the lives of Minors )
			Inward No.		Date.
To be filled in by Agent: Division Code:		Branch Office Code:			FOR OFFICE USE ONLY :
Agent’s Name:
Agent’s Code :	Dev. Officer Code:				Proposal no :
Ag .License No.	Date of Expiry	:			Amt of Deposit :
	(yyyy-mm-dd)				B.O.C No.
Proposal. Dt :	Medical Code	:---			Date :
(yyyy-mm-dd)

(All answers to be filled in legibly. Answers must be given in Words. Stroke of the pen or dot or dashes will not be accepted as replies.

In case you are using a pc to fill , Please select the appropriate from the dropdown menu provided , dropdown key is f4 , help key is f1. )

2A	Residential address, if different from above :					Nature of Age-Proof submitted:
Addr1:
Addr2:						---
Addr3:
Pin:
						Age (nearer			Date of Birth
e-mail:						birthday)
							.. Yrs		(yyyy-mm-dd)
Short Name :			Father’s Full name (Surname First )
2B. Nominee’s Full name(Surname first) and address				Age	Relationship to		Title Code
					yourself
Name :					---		---
Addr1:					(Please select the		(Please select the appropriate from the
Addr2:					appropriate from		dropdown menu provided in case filling on
							pc )
Addr3:					the dropdown
					menu provided in
Pin	:
					case filling on pc
					)
If Nominee is a minor, appointee’s full name and address				Age	Relationship to nominee			Signature of Appointee
								as token of consent

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Life Insurance Corporation of India

FORM NO.300(Rev 02)

Name :

Addr1:

Addr2:

Addr3:

Pin :

Note: It is in the interest of the Proposer to avail the facility of nomination

3

Plan

Policy

Prem-

Sum

Term rider

Critical

Is accident

Sum Assured

Date of

Total

Term

ium

Proposed

sum

illness

Benefit

For the

Commencement.

Amount

Term

proposed (if

sum

required?

Accident

If policy is to be

Deposited

required)

proposed

dated back

(if

Benefit.

indicate that date

required

(yyyy-mm-dd).

---

Boc1- No. Boc1-Date

Boc2-No.

Boc2-Date

Boc3-No

Boc3-Date

Boc4-No

Boc4-Date

Mode(Yly, Half-

Paying Authority Code

Deptt. No.

Badge or S.R. No.

Yly,Qtrly,Mly,

SSS ,Single )

---

PA:

Sub PA:

4A. Present Occupation

Exact nature of duties

4B. Name of Present Employer

Length of Service with him (years)

5 Educational Qualification

Annual Income

Source of

Are you an Income Tax

(Rs In ‘000 )

Income

Assessee ?

,000 .

---

6. If you are employed in the Armed forces, please state

---

Wing to which you

Rank therein

Date of last Medical

Medical Category after

Were you ever below

belong

Examination

Medical Examination

A-1 category ? if so

(yyyy-mm-dd)

when ?

---

7. Is your life now being proposed for another assurance or an

YES/NO

DETAILS

application for revival of a policy on your life or any other

proposal under consideration in any office of the corporation or

---

to any other insurer? If yes give details .

8A. Has a proposal( or an application for

Answer

If yes give details

revival of a policy) on your life made to

‘YES’ or

any office of the corporation or to any

‘NO’

other insurer ever been :

Withdrawn , Deferred , Dropped or

---

Declined ?

Accepted with extra Premium or Lien ?

---

Accepted on terms otherwise than those

---

proposed ?

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Life Insurance Corporation of India

FORM NO.300(Rev 02)

9.

Please give details of your previous insurance : ( including policies surrendered/lapsed during last 3 years)											!PPL#!
Policy	Insurance	Table	Sum	Term	Critical	Amount	Year	Whether	Med	Whethe	If not
number	Companies from	&	Assured	Assuran	Illness	Of	Of	accepted	ical	r in	give due
	where previous	Term	On	ce	Rider	Acciden	Issue	as	Or	force	date of
	policy/policies							proposed	Non		last premium
	have been		Main	Rider	Sum	t		at ordinary	medi	for full	paid or date
	purchased with		Plan	Sum	Assured	Benefit		rate, if not	cal	Sum	of surrender
	address ( if			Assured		Taken		give		Assured
	previous policy							details
	are from LIC of
	India, give name
	of Branch/DO)
									---	---
									---	---
									---	---
									---	---
									---	---
									---	---
									---	---
									---	---
									---	---
									---	---

N.B. : Corporation does not entertain any fresh proposal for insurance where a policy issued by the corporation has lapsed or has been converted into paid up policy within the last 3 years. !PPL#!

10. Family History .

	Living		Dead
	Age(.,.,.)	State of Health	Age at death	Cause of death
Father
Mother
Brother
Sister

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Life Insurance Corporation of India

FORM NO.300(Rev 02)

Wife/Husband

Children

11.

Personal History			Answer	If ‘yes’, Please give full details
			‘Yes’ or
			‘No’
(a) During the last five years did you			---
consult a Medical Practitioner for any
ailment requiring treatment for more
than a week ?
(b) Have you ever been admitted to any			---
hospital or nursing home for general
check up, observation, treatment or
operation ?
(c) Have you remained absent from			---
place of work on grounds of health
during the last 5 years ?
(d) Are you suffering from or have you			---
ever suffered from ailments pertaining
to liver, stomach, Heart, Lungs ,
Kidney, Brain or Nervous System ?
(e) Are you suffering from or have ever			---
suffered from Diabetes, Tuberculosis,
High Blood Pressure, Low Blood
Pressure, Cancer, Epilepsy, Hernia,
Hydrocele, Leprosy or any other
disease ?
(f) Did you ever have any bodily defect			---
or deformity ?
(g) Did you ever have any accident or			---
injury ?
(h) Do you use or have you ever used -
Alcoholic drinks			---
Narcotics			---
Any other drugs			---
Tobacco in any form			---
(i) What has been your usual state of			---
heath?
(j) Have you ever required or at present			---
availing/undergoing medical advice,
treatment or tests in connection with
hepatitis B or AIDS related condition.
12. In non-medical cases , please state			Height ( Cms )		Weight ( Kg )
exact height in Cms. And weight in Kgs
( Without shoes )
		FOR FEMALE PROPONENT
13A Are you		Date of last delivery	Have you had any abortion or miscarriage or			Date of last Menstruation
pregnant now?		(yyyy-mm-dd)	Caesarian section ? if so give details			(yyyy-mm-dd)
---			--- Details:

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Life Insurance Corporation of India

FORM NO.300(Rev 02)

13B. Husband’s full name

His Occupation

His annual Income

13C.

Details of husband’s Insurance :

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Life Insurance Corporation of India

FORM NO.300(Rev 02)

DECLARATION BY THE PROPOSER

Ithe person whose life is herein being proposed to be assured, do hereby declare that the forgoing 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 absolutely null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the corporation .

Not-withstanding the provision of any law, usage , custom or convention for the time being in force prohibiting any doctor, hospital and/or employer from divulging any knowledge or information about me concerning my health or employment on the grounds of secrecy, 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 agrees 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 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 any application for revival of a policy on my life made to any office of the Corporation has been withdrawn or dropped, deferred or accepted at an increased premium or subject to a lien or on terms other then 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 assurance invalid and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.

Dated at ……………………………… on the ……………………….day of ………………..200

Signature of witness …………………………	Signature or Thumb Impression of the Person whose life
Name	Is Proposed to be assured .
Occupation
Address

1)Declaration by the person filing in the form ( in case form is filled up Signed in a language different from that of the Proposal form.

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 .

Declarant’s Name and Address …………………………….

…………………………………………………………………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 thumb impression should be attested by a person of standing whose identity can easily be established 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 this form to the proposer in …………….

language and that the proposer has affixed the thumb impression above after fully understanding the contents thereof .

Name and Address of the declarant :

…………………………………………………………

…………………………………………………………SIGNATURE

SUMMARY OF SECTION 45 OF INSURANCE ACT, 1938

No policy of life insurance shall, after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend

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Life Insurance Corporation of India

FORM NO.300(Rev 02)

of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making it that statement was false or that it suppressed facts which it was material to disclose.

Note: “Material” shall mean and include all important, essential and relevant information in the context of underwriting the risk to be covered by the Corporation.

INSURANCE ACT 1938 UNDER SECTION 41

1)No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the Premium shown on the policy nor shall any person taking out renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer. Provided that acceptance by an insurance agent of commission with a policy of life insurance taken out by himself on his own life shall not be deemed to acceptance of a rebate of premium within the meaning of sub-section if at any time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bonafied insurance agent employed by the insurer.

2)Any person making default in complying with the provision of this section shall be punishable with fine which may extend to five hundred rupees.

FOR MEDICAL CASES ONLY

I certify that the Life Assured has signed / put his/her thumb impression in my presence after admitting that all the answers to Questions Nos 10 onwards of this form have been correctly recorded .

………………………………………………..	…………………………………………….
Signature or thumb impression of the Proposer.	Signature of the Medical Examiner.

NB. Signature or thumb impression should be affixed in presence of Medical Examiner.

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