LI-01

DEPARTMENT OF POSTS INDIA

PROPOSAL FOR RURAL POSTAL LIFE INSURANCE
(NON-MEDICAL)

Name of BPM/GDS
PM/GDS MC etc.

DA

For office use only

CHECKED ACCEPTED/REJECTED
HC/SS Sr/Suptd/ASP

Name of Sales person/Agent ............................................................................

Date of proposal .........................................

......................................................................................................................... No of LI-2 ................... date ...................
Amount deposited ...................................
Code No. .........................................................................................................
Post Office at which deposited ...............
Code alloted by
Checked/
division
Accepted/Rejected ..................................
Policy No. ...................... issued
on ............
Full Name of
Proposer
1.

Name in full (In Block letter) .................................................................................................................................

Father's or Husband's Name

2.

3.

Father/Husband Name (In Block letter) .................................................

Full Address
as per proof

Permanent Address
Vill ..........................

Post Office ..........................

Pin Code ..........................

Mobile number ..........................

Distt ..........................

State ..........................
Certificate

4.

Date of Birth ...........................................

Age on next birth day .................

5.

Mark of Identification ..............................................................

Nature of proof of age ...................

Any Scar / Mole

6.

Type of policy / age

on maturity

Sum Assured

Amount
premium/
periodicity

Rs.

Rs.

Details of policy
he want's to purchase

Mode of payment
Cash/Cheque

Periodicity
of premium
deposit/PO

7.

Nomination under section 39 of Insurance Act-1938 (Not applicable in case of policy under MWPA-1874)
Full name of
nominee

Full address of
nominee

Relationship to
Proposer

Age of Nominee
Nominee details
i.e., wife, parents,
child etc.

8.

In nominee is a minor, do you wish to appoint a person to receive policy money

during minority of the nominee ? If so, please give details with consent of the appointee
Full name &
address of the
appointee

8.1

Consent & Dated

Signature of the
appointee

Relationship to
nominee

Age of Appointee

Present Occupation and annual income (inclusive all sources)

Obtain his/her occupation

i.e. Farming, Business,
Service etc.

................................................................................................
9.

If policy is proposed to be taken under Married Women's property Act 1874

state object particulars of beneficiary and particulars of trustee :
................................................................................................

10.

Leave in Blank

Du you hold any other Rural Postal life Insurance policy, if so, give details .
Obtain details of other
policies and see that
limit of Rs. 25,000/not crossed.

................................................................................................
................................................................................................
11.

Nominee in
minor detailed
appointee
if any

Declaration of the proposer (a) I .......................................................................... hereby declare that I am

in good health and free from diseases. That I have not had any serious
illness or major operations for the last three years and that no proposal of
insurance on my life has ever been adversely treated.
(b) I .......................................................................... hereby declare that the
foregoing statement made are true to the best of my knowledge and
belief. Incase, I have willfully made any untrue statement or have
concealed any circumstances with regard to which information has been
required from me then all the premium which shall have been paid by me,
shall be frofeited and the contract rendered absolutely null and void.
Surrender of a policy is not admissible before completion of 36 months
of the policy and the amount deposited shall be forfeited.

Proposer to
declare that
he is in
good health
condition
information is
correct and limit
of Rs. 25,000/of Policies not
crossed

(c) I .......................................................................... hereby declare that the

sum assured limit /value of all RPLI policies (non medical) taken
together held be me does not exceed Rs. 25,000/-

(Signature or left thumb Impression of the proposer)

If Proposer is illiterate
he will put his thumb
impression after
having understood
everything
12.

13.

Declaration in case the proposer is illiterate

Note :- In case the proposer is illiterate the thumb
impression of the proposer should be attested by a
literate person permanently resident of the locality
(but unconnected with the Deptt) and this declaration
should be made by him.

I hereby declare that I have explained the contents of

this form to the proposer in .....................................
(Language) which he/she easily understands and that
the proposer has affixed the thumb impression above
after fully understanding the contents thereof.

Declarant's Name ...............................

Signature ................................

Address ..............................................

Date ........................................

Declaration of the Rural PLI Sales Person (Agent, GDS, D.O./FO, Deptl
employee)
I .......................................................................... certify that the above
information including declaration of health has been furnished by the
proposer in my presence.
I further certify that the document in proof of date of birth furnished by the
proposer has been personally verified by me and the date of birth is found to
have correctly stated. I recommend/not recommend the acceptance of the
proposal.

Signature of RPLI Agent

Dated .............................
Station ...........................

You have to
verify his
date of
birth and
certify that
information
above is
correct.

Name and Address of

Proposer (Insurant)

This report to be
given by
SDI / ASP

Confidential Report
This will consist of information not revealed in the proposal from SDI/ASP report is not only required for granting a
policy but will also be required then claim arises to check the correctness of data in proposal form. This will be
completed by SDI/ASP after proposal form is completed by proposer, content of the report should not be discussed with
proposer or divulged to him.

(The form should be completed by SDI/ASP)

1.

Are you related to proposer ?

Yes/No

2.

How long you have know proposer ?

1/2/3

3.

Do you know the family of the proposer ?

Yes/No

4.

Are you aware of any financial/physical/mental

situation concerning proposer which makes him
unsuitable for consideration of Insurance policy ?

5.

Has the proposer completed the form in confirmity. If this

is not so, the reason for not completing the same ?
:

6.

Are you convinced to his reasons for not completing

the form ?

Yes/No

7.

Has the signed proposal/Declaration Form ?

Yes/No

8.

Any other matter you would like to bring to the notice

of DPLI.

Yes/No

9.

Do you recommend the acceptance of the Policy ?

10.

If not recommended give reason

11.

In case of any doubt please visit the concerned police

station and verify of the proponent was ever arrested/
convicted in the criminal case. If yes, give details.

12.

Please confirm that :(1) Confidential report has been written by you after
Completion of proposal form by proposer.

(2) Confidential report has not been divolged to

proposer/or discussed with him.

Confirmed/Not Confirmed

Signature SDI/ASP
Full Name with Stamp

FOR MEDICAL POLICY

PLI-01

RURAL POSTAL LIFE INSURANCE

DEPARTMENT OF POSTS INDIA

FOR OFFICE USE ONLY USE CODE ONLY

_______________________________________________________

IMPORTANT NOTE

DATE OF RECEIPT ....................................................

_______________________________________________________

1. THIS FORM IS MEANT FOR INSURANCE OF

OWN LIFE ONLY.
2. PROPOSER SHOULD MAKE HIM/HERSELF
FAMILIAR WITH TERMS AND CONDITIONS
AND RULES OF THE SCHEME BEFORE FILLING
IN THE FORM EITHER HIMSELF OR THROUGH
HIS AGENT.
3. ALL ANSWERS SHOULD BE FILLED IN
LEGIBLY DOTS, DASHES OR BLANKS WILL
NOT BE ACCEPTED.
4. P R O P O S E R S H A L L B E R E S P O N S I B L E
PERSONALLY FOR THE INFORMATION FILLED
IN THIS FORM IRRESPECTIVE OF WHETHER
THE FORM IS FILLED IN HIS OWN HAND OR
THROUGH HIS AGENT. ATTENTION IS INVITED
TO RULE 7 OF POIF RULES FOR INACURATE,
WRONG OR MISLEADING INFORMATION
GHIVEN BY THE PROPOSER WHICH MAY
RESULT INTO CANCELLATION OF THE POLICY
AND FORFEITURE OF ALL MONEYS PAID THE
PROPOSER.

CIRCLE WHERE ACCEPTED ...................................

CIRCLE WHERE SUBSEQUENTLY TRANSFERRED
1.

2.

3.

4.

5.

6.

AGENT
HO
CODE
CODE
_______________________________________________________
POLICY NO. ........................................................................
_______________________________________________________
SUM ASSURED ..................................................................
.
PLAN ........................... TYPE ..............................................
TERMS ........................ YRS ENTRY AGE .........................
MATURITY AGE .................................................................

TO BE FILLED IN BY THE PROPOSER IN HIS

OWN HAND OR THROUGH HIS AGENT
DATE OF DN NOTICE .........................................................
1. SUM PROPOSED (IN FIGURES ........................
(IN WORDS) .......................................................

LAST PREMIUM DUE ........................................................

2. TYPE (MED/NON MED) ....................................

DATE OF MATURITY .........................................................

_______________________________________________________

3. PLAN (WI./CWL/EA/AEA) ...............................

4. TERM ................... 5. MATURITY AGE..............

AEA SURVIVAL BENEFITS

1st

2nd

3rd

6a. MODE (CASH/PAY) ...........................................

6b. PERIODICITY ....................................................
7. NAME .................................................................
(SURNAME FIRST)

CWL DATE OF
CONVERSION

PREMIUM
PERIODICITY

PREMIUM MODE ...............................................................................

PAYMENT PERIODICITY ..................................................................

8. SHORT NAME ....................................................

(SURNAME FIRST)

DETAILS OF P. O. ................................................................................

9. FATHER'S/HUSBAND'S ADDRESS ................. AMOUNT .............................................................................................

..............................................................................
10. PERMANENT ADDRESS ..................................
(RESIDENTIAL) ................................................
.............................................................................
.....................................PIN..................................
11. ADDRESS FOR CORRESPONDENCE .............
(IT BE INCORPORATED IN POLICY BOND)
.............................................................................
.............................................................................
.....................................PIN..................................

PROVISIONAL 1st PREMIUM

UNDERWRITING DATE
RISK DATE
AGE .............. AGE PROOF CODE ......................... SEX ...................
PREMIUM

12. NATIONALITY ......................... 13. SEX ..........

14. EDUCATION QUALIFICATION .......................

DATE OF COMPLETION

15.

a. DATE OF BIRTH .............................................

b. AGE ON NEXT BIRTHDAY ...........................

Mention any prominent

mark of identification
of proposer

c. PLACE OF BIRTH ..........................................

d. NATURE OF AGE PROOF .............................
16.

IDENTIFICATION MARKS (TWO)

a. ................................................. FINAL UNDERWRITING

b. ........................................ PROPOSAL ACCEPTED/REJECTED

AUTHORIZED SIGNATORY
FULL NAME
DESIGNATION
17.

IF POLICY IS PROPOSED TO BE TAKEN UNDER

MARRIED WOMEN PROPERTY ACT 1874, STATE
OBJECT PARTICULARS OF BENEFICIARY AND
PARTICULARS OF TRUSTEE.
(NOMINATION IN SUCH CASESS NOT ALLOWED)

Nomination Facility
available So, mention
'No' here

18.

IF POLICY IS BEING FUNDED BY HUF GIVE

PARTICULARS OF HUF.

19.

NOMINATION (REFER SECTION 39 OF INSURANCE ACT 1938) (NOT APPLICABLE IN CASE OF POLICY
UNDER MWPA 1874)
a.

STATE PARTICULARS OF THE NOMINEES (NOT MORE THAN THREE NOMINEES)

SOLE/FIRST NOMINEE

SECOND JOINT NOMINEE

THIRD JOINT NOMINEE

NAME ...............................................

NAME ...............................................

NAME ...............................................

ADDRESS .........................................

ADDRESS .........................................

ADDRESS .........................................

............................................................

............................................................ ............................................................

............................................................

............................................................ ............................................................

RELATIONSHIP ...............................

RELATIONSHIP ...............................

RELATIONSHIP ...............................

AGE ...................................................

AGE ...................................................

AGE ...................................................

% SHARE OF CLAIM AMOUNT .....

% SHARE OF CLAIM AMOUNT .....

% SHARE OF CLAIM AMOUNT .....

b.

IF ANY OF THE NOMINEES IS A MINOR. PLEASE STATE THE NAME OF THE PERSON WHOM YOU WISH
TO APPOINT TO RECEIVED THE POLICY MONEY IN THE EVENT OF THE CLAIM ARISING DURING
THE MINORITY OF THE NOMINEE

NAME OF THE APPOINTEE ................................................................... RELATION ........................... AGE .................

ADDRESS ..........................................................................................................................................................................
SIGNATURE OF APPOINTEE
20.

PARTICULARS OF ALL OTHER POLICIES HELD

(EVEN THOSE UNDER REVIVAL, INCLUDING PLI)

POLICY NO.

AMOUNT

INSURER

........................
........................
........................
21.

HAS ANY OF YOUR PROPOSALS BEEN EARLIER REJECTED

OR EXTRA PREMIUM LEIVED THEREON BY ANY INSURER>
GIVE DETAILS.

........................
........................
........................
........................
Details ........................
of earlier
........................
policies by insurant
.......................................................................
.......................................................................
.......................................................................

22.

OCCUPATION AND INCOME PARTICULARS

.......................................................................

23.

(a)

Family History
Fill up this when any of
near relative are dead

Only in case following near relatives

Age at time
of death

Cause
of death

Father
Mother
Brother/Sisters
(b)

PERSONAL HISTORY

i.
ii.

PRESENT STATE OF HEALTH

STATE IF YOU HAVE ANY DEFORMITY DEFECT
OR IMPAIRMENT ? GIVE DETAILS.

Deformity/illness
by birth
CONGENITAL

Deformity/illness
after birth
POST CONGENITAL

24.

HAVE YOU EVER SUFFERED FROM ANY DISEASE IN RESPECT IN RESPECT OF FOLLOWING/MORE ? IF
SO, GIVE DETAILS :STOMACH OR DIGESTIVE SYSTEM, HEART CIRCULATORY OR LYMPHATIC SYSTEM, LUNGS OR
RESPIRATORY SYSTEM, BRAIN OR NERVOUS SYSTEM, KIDNEY OR EXCRETARY SYSTEM, BONES
SKELTERN SYSTEM/JOINTS, SEXUAL ORGANS OR REPRODUCTIVE SYSTEM, SENSE ORGANS,
MUSCLES, SKIN, ORENDOCRINE LANDS AND HIV+ AND AIDS.
______________________________________________________________________________________________

25.

HAVE YOU BEEN ABSENT FROM YOUR PLACE OF WORK ON GROUND OF HEALTH OR HOSPITALIZED
DURING LAST THREE YEARS ? GIVE DETAILS. ........................................................................................................
.............................................................................................................................................................................................
Has the proposer taken
______________________________________________________________________________________________
any medical leave etc
in service
FOR FEMALE PROPOSERS ONLY
______________________________________________________________________________________________

26.

(i)

ARE YOU MARRIED R SINGLE ?

...................................................................................................

(ii)

No. OF CHILDREN ..................................... (iii) DATE OF LAST DELIVERY ...............................................

(iv)

IF PREGNANT THEN DATE OF DELIVERY .................................................................................................

27.

Telephone Number Office ........................................... Residence ...........................................

28.

Bank A/c. Number ........................................... Address of Bank ........................................... ..........................................

Also mention
Mobile
Number
............................................................................................................................................................................................
E-mail if any

______________________________________________________________________________________________
FOR MEDICAL CASES ONLY
______________________________________________________________________________________________
I certify that the proposer has signed/put his/her thumb impression in my presence, after admitting that all the answers to
questions No. 23 and onwards of form have been correctly recorded.

.......................................................................................
Signature or thumb impression of the proposed
NB-Signature or thumb impression should be affixed in
The presence of medical examiner

.......................................................................................
Signature of the medical examiner
Designation
Seal
Date

DECLARATION BY THE PROPOSER

I ......................................................................... 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 all respects 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 Department of Posts and that if any untrue avernment be contained there in the said contract shall be
absolute null and void and all moneys which shall have been paid in respect there of shall stand forfeited to the Department.
Notwithstanding 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 on the grounds
of secrecy. I, my heirs nominee, executors, administrators and assignees or any other persons 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 department.
And I further agree that if after the date of the submission of the proposal but before the acceptance of the proposal, (i)
any change in my occupation or any adverse circumstance connected with my financial position or the general health of myself or
that of any member 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 Department has been withdrawn or dropped, deferred or declined or accepted at an increased premium or subject to
a lien or a term other than as proposed. I shall forthwith intimate the same to the Department 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 there of forfeited to the Department.
a)
The contents of surrender table and instruction for admissibility of surrender value have been explained to me before taking
policy and I abide by the same.
b)
Surrender of a policy is not admissible before completion of 36 months of the policy and the amount deposited shall be
forfeited.
c)
On surrender, the policy shall attract proportionate bonus on reduced sum assured up to the date for which premium has been
paid. However, no bonus shall be payable before completion of 5 years of the policy.
d)
The discontinued policy shall not attract bonus with effect from the date from which the premium is discontinued.
e)
The reduced sum assured shall be calculated by multiplying the sum assured with the number of instalments paid and
dividing the same with the total number of premiums to be paid.
f)
The surrender value shall be calculated by multiplying the sum of reduced sum assured plus the proportionate bonus, if any,
with the surrender factor as applicable on the attained age as on the date of surrender of the policy.
Signature of witness
Name ...................................... Occupation ...........................................
Address .................................................................................................

Signature/thumb impression of the person

whose life is proposed to be assured.

Note : If in this form the answers to the questions and / or signature of the proposer hereinabove are/is in vernacular then he/she
should declare above his/her signature in his/her own handwriting that the replies are given after fully and properly
understanding the same.

Declaration by the person filling in the form

Declarant's Name .......................................................
Address ......................................................................

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

...................................................................................
...................................................................................

........................................................................................
Signature of Agent or the person filling the proposal form
Date ...............................................................................

Declaration in case the proposer is illiterate

Note : In case the proposer is illiterate the thumb impression
of the proposer should be attested by a person of standing
whose identity can easily be established but unconnected with
the Deptt. and this declaration should be made by him.

I hereby declare that I have explained the contents of this form

to the proposer in ....................................................................
(Language) which he/she easily understands and that the
proposer has affixed the thumb impression above after fully
understanding the contents there of

Declarant's Name ...................................................................

Address ..................................................................................

Signature ...............................................................................
Date ...............................................................................