| Ic ¢ LIC CARDS SERVICES LTD. Date (Regd. Office : 6th Floor, Jeevan Prakash ‘Stamp CARDS | "2S oritesaifoin Tol Free No.- 1800223033 scpicaton Serial No. WO0000020046 [ Application Form for Credit Card Instructions: 1. Please fill in all columns with required detalls in BLOCK LETTERS. 2. Absence of mandatory information may result in rejection of application. Tick [] boxes where appropriate and write N.A. if not applicable. ar 3. Submit all documents as requested at the end ofthe application form. Peer 4, Most Important Terms & Conditions (MITC) is available at LIC CSL office and published in Photograph. ‘our website http://mwwliccards.com Do not Staple Please sign here in Black Ink—» formation (Fields marked wit! 4.*Name : MrJMre/Ms.| FirstName 2. Narn to be embossed onthe Card: (Max. 3. “Date of ith: 6. “Legal status: Resicent{_] nai [] P10 8, paves CITT ETT TT & sovoters 0: [T TT TTT TTT 1+ 12.*Vehice:2 whosler[] 4 whoate 13, *Mother's Maiden Name: I 14. *Name of Nominee (for insurance facility) “Relationship wth Applicant [TT TT TTT TTTTITTITITTItitt) Er iba nn 15. Occupation: Salared[_] Sef Employed [|] Protssonal[ ] Rete [ ] Housowie [_] Others 6 PSU [] MNCL] Prvate[—] Parnocsiel] Others 7. Employed for. No| 8 ‘actvties: CA [] Doctor [—] Lawyer [—] Consultant [“] Engineer[—]Others[—] No. of years... 19. a) IFLIC staf, S.No, yoar of Joining . ) HLIC Agent, Agency Code No. [TTT TTT TIT] Tn) oy Site “PIN (Please attach proot ofthis addrese)24, Type of Present Residence : Owned by Self/ Spouse |] Family Owned [_] Rented [_] Company leased or Quarters [] 22, Permanent Residential Address (Only if diferent from present Residential Address) oy State "PIN Stale “PI obleNods. E-mail ID: “son orate Esai: sis De you wish o aval the fcily of mobil alerts on your above mobile number Yee [-] Nol_] De You wish to aval the fcity of receiving statomentsfather Information by e-mail: Yes ["] No[_] understand that the alert facility will enable me to receive customer alert messages with respect to events/transactions relating tomy Credit Car/LIC Poly a Information Promational Matra thereon, over my mabie Phone or thveugh e-mal | agreeto abide by te terms and concons of LIC Carés Services Ld. nhs regard, lundertake to keepLIC CSL Informed whenevertherels any changein thee mallD or Mobile Phone infutro. 25, Addon () Name otApebcnt TTT TTTTITTTITITI 11] daeteen TTT TTT Relationship: [_] Spouse Cy Parents LJSiblings —~ [Jehildren (Above 18 years) 26. Add on (i) Name of Appiicant{ | | | TTT TTT TTT TTITIT | Date of Birth | TT TT TTT) Relationship: [_] Spouse i Parents Cisibings —_[_]children (Above 18 years) Sonate fhe alone nein rect | Sent ofa atoncard hacer Tact ‘black in colour Stamp size | black in colour Stamp size Photograph. Photograph. Do not Staple Do not Staple rch eee) 28, a. Salaried applicants please provide the following details: Gross monthly income..... Other income. . Other than salaried appli Gross monthly income... Eid ee) 29, Send Statement of Account to: Office Address [-] Present Residential Address [_] 30. Do you want to avail Auto Debit faciity on your CorpBank account (for Corpbank customer only) YES ["] NO [_] ltyes, Ale Type. AIG NO. Senn th BYANGH nnn Brantch Code [T_T] iy. 31, Amount to be debited: Full Amount Due [_] Minimum Amount Oue [_] Documents Furnished (auifteids are mandatory) Only Latest Documents should be submitted 32, Proof of residence: Telaphone Bil [_] Passport [_] Llconse [_] VotorID [_] Company Lettor[_] Electricity ai] 2, Proof of income : For Salaried employees : Salary Sip [_] Salary Certficate [_] For Others :ITRetums[_] F 161] 24, PANGad DeductionsDETAILS OF LIC POLICIES The nine dig policy number's to be given. In case of lesser digit numbers, zeroes may be prefixed. ‘Whether wish to pay }s. | Policy numbert Date | Name of Relation- |Sum insta | Montini No of the ship [Assured | iment [ary | premlum through Lic ‘Comme- | insured ith Premium |Hyivivety| card (tick appropriate neament [cardholder ‘Amount solumn) Yes No Note: if you want that whenever the premium of a policy falls due it should be paid automatically by charging ito your LIC Creal Card, plaase tick tne column "Yes" in respect ofthat policy otherwise tick "No" *" In case, more than 10 policies, please give detals in a separate annexure, duly signediauthenticated, * Mandats for premium payment through LIC card cannot be accepted in case of ULIP policies, Policies with monthiy'SSS mode and lapsed policies. Declaration hereby declare thatthe pertculars givan above are correct and complete. | express my wilingness to remit the premiumis refered to above through LIC card. hereby authorise Corporation Bank to remit the premia of my LIC policies as per my mandate given above, 5 days before the end of grace period n each ease. If any transaction is delayed oF nol effected al all for the reasons of incomplete or incorect information of rron-avaliabilty of credit onthe LIC creditcard, | would not hold LIC, LICCSL or Corporation Bank responsible. "understand thatthe process of remittance of premium through the LIC card would stat only after confimation or registration of policy details by LIC and the same wil be intimated to me. Inthe meantime, | would continue to pay the premia on my palcies. We hereby dociare that Ve havo porsonally read and understood tho terms and conditions governing the issue and usago of tho creditcard, We very that contents stated inthe above Application ara trus tothe best of my/our knowledge. I/We hereby authorize the LIC CSL andlor is ‘associates to vey any information proviced inthe applicalon Form at any gven time. (We also confi that /We shall inform the LIC CSL of ‘any change in the information mentioned above. VWe agree that the card willbe Issued to me/us upon the prevailing tems & condlions (Subject to change from time to tine) ofthe cart member agreement. |, asthe applicant ofthe Primary Card, shal be liable fr ali charges incurred on the Primary Card and all add-on cards. IWe agree to pay the membershiplannual fees and other charges which willbe fixed from time to ime, hereby authorise LIC CSL to share my credit information wilt CIBIL or any statutory authorly as deamed Mt Date” ‘Signature | hereby deciare that this Application Form has been filed in my presence. | certify that address fumished by the Applicant is verified by me and is rue tothe best of my knowledge. | further certify thatthe LIC Policy Details as furnished above are correct and the Policies are in force. | recomend for favourable consideration, “LIC CSL Rep. Code No. NAME OF THE REPRESENTATIVE WITH STAMP & ADDRESS : Signature Date Mobite No.: [TT TTTTTTT) For Office Use: Sanctioned for Card Limit of Rs. For Corporation Bank Chief Manager /Asst. Gen. Manager LIC Gard Centre: New Delhi