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Affix here your

recent passport
size photograph

(Altentries.houtd be o,,.o,r.i#fo???t:)FoRM
AgenUAdvis;r Code:.

AgenUSales person Name: .Group Leader Name &Code:.

Date of Declaration
Produc.t/ Policy Type: EwuDcwutreetrnee Eev
Do you already have any PLURPLI policy: Yes / No
Customer lD (for existing customerg)

i. Name of Proponent flMr. DMrs. fl lvts.1

ii. Aadhaar No. (optional) iv. PAN_ (optional)

iii.f]Father's Name oR fl Mothels Name

iv. Gender vi.Marital Statusfl Married E Unmanied fl Others

Uu nr fl others

vii. Age Proof: lfick ({) wnicnever is applicable]

(Standard Agc Proo0 _
fl airttr Certifi eate
f] Matriculation Certif cate florivlng License [Passport flnnru flottrers
Non standard Age Proof: (please specify)


Number of Children Are you Pregnant now?
Are lf pregnant, expected month of delivery

Yes I lNo

iCorrespondence Address
Tick here if permanent address is same ({}
Correspondence Address: Permanent Address:

Village/Locality; Village/Locality:
Post Office: Taluka/District: _ Post Office: Taluka/District: _
State: Pincode: State: Pincode:
Mobile No: Mobile No:
Email address: (if anv) Email address: (if anv)


)AN No, (if any)

ulonthly lncome

@(refer Section 39 of lnsurance act 1938)

a. Details of Nomination (Not more than 3 nominees)
Name& address of the ttlomlnee(sl Gender Date of Birth Aadhaar f{o. Relationship Share of Mobile &€mail lD
(MlFlother) {DD/MM/YYYYI {optional) Nominee(r) 96


,b. Appointee D_etails (lf nominee is minor)

Relationship. M[:] Ffl

Date of Birth ffi
Mobile No.

C. Particulars of beneficiary(ies), if policy is taken under Married Wornen Property Act 1874, (nomination in such cases are not


for PLI/RPLI Policies both ie Rc.50,00,0004.

i. ii. lnitial Premium Payment Mode iii. Subsequent Premium Payment ModeCash I Online

iv. Premium Payment Frequency MonthU [--l Quarterly f_l HalfYearty [-*l YearU f'l

a. Ar.e you in sound health at present? Yer INo

High blood pressure, angina" heafi attacl( stroke or any other disorder of heart or circulation?

Kidney or liver problem?

pneuffionia, TB or any oth6l resplratory or

Ulcer, chronic diarrhea, hepatitis or

Mental or nervous illness (including depression) lasting for more than 3 months and/or requiring more than 10
consecutive days off work?

related complication ortest indicating presence of

Any other illness, surgery or

d. Do you have any physical deformity or c.ongenital by birth defects? Yes n

lf Yes, please provide details below:
moneys v.irich shall have been paid in respect thereof shall stand forfeited to the Doparbnent.

Not*ith.,t.n4,nn tho provision of any law, u6age, curtom or convontion for the time boing in forc6 prolribiting any doctor, hosFital and/or enrploysr from
divulging ai7 knoliledge or information about me concaming my health or on the grounds of secr€cy I, my heirs nominae, exocutors, administrators and
aeelglnels oi any other-persons or persons having intorest of any kind whateoevar in tho policy contraot issued to_ m6, horeby agrBe, that such authority, having
suct kno,vledgsor information shall at any time b€ at liberty to divulge any such kno^rledge or information to the Deparhlent.
And I further agree that if after the date of the submission of ths propGel but bsforo the acceptanc€ of tho proposal, (i) any change in my occupetion any
adverse circumstance connected with my financial preition or the gen€ral hoalth of my.etf or that of any m€mber of my family occurs or (ii) if a propoeal for
assurance or an applbation for rovival of a policy on my lif6 made to any offics of the Oepartnent has boen withdrawn or dropped, dsfened or declined or
accepted at an inorease premium or subjoct to a lien or a tEm other than as propo€Ed, I Shall fortlwith ifiimate the samq to the Dbparfrent in writng to
reconsidEr the terms of acc€ptance of e66urance. Any omtssion on my part to do €o shall ronder this assurance invalld and all moneys \,vfiich 6hall havB boen
paid in respect thereof forfeited to the Department.
gbide by
al The contents of surrend6r table and instructions for admissibility of surrender vaiue have been explained to me before taking policy and t
b) Surrender of a policy b not admiGsible before completion of thirty-six months of the policy and tho amour* doposited shall be forfoned il I

surrender the policy within thirty-sixmonths.

c) On surrender, the policy shall attract proportionate bonus on roduced sum assurod up to the date for which premium has be€n
d) Thedi$continuedpolicyEhallnotattrastbonuqwrthsffectftomthedatefrarfirvhichthepremiumicdigcQntinued.
e) The reduced sum assured shall be calculated by multiplying tha sum a$ured with the number of instalments paid and dividing the sam€ with the
total number of premiums to bepaid.
f) The surender value shall be calculated by multiplying the sum of reduced sum assured plus the proportionate bonus, any, if
I .--*- -- ,.SonlWife/Daughterof aged years do hereby declare that:

i.t am not suffering from Hypsrtension & Diabate6 and not taking any tBaunent for Hypertension &
t have been suffering from Diabetes/Hyp€rtension from the last yoarc but with proper medical adice & medication it is with in control
and no complication has surfaced so far pooing any threat to my life.

not accepted.
- been explained about the featuroa of the product and I believe, it would be suitable
The above reoommondation is based on the information provided byme. I hav€
for me based on my insurance needs and financial objectives.

Proponent's Signature /
Thumb lmpression {*f<.
(in case proposer is illiterate)

Dated: ffi
10. Declaration in case the proooser is illiterate. and forn!.-is filled bv porEon other than proooser

hereby declare that I have explained the content of this form to the proposer in
(Language) which he/she easily unders{ands and that the proposer has affxed lhe thtmb impression
above after fully understanding the contents there of. I have carefully filled up the proposal form.


Dedararfs Name:


I AgefttCode NoJID working asin_

*BO/SOunderDivision declare that the information (personal, financial & medical) in'the proposal form has been trrnished by the
proponent and it has been signed by him/his thumb impression has been taken in my presence, All columns have been completed and have
been verified and found correct to best of my knowledge. I am fully awareabouttinanciallphysicaUmental situation concerning proposer
which makes him suitable/unsuitable for lhe consideration of his lnsurance proposal. The proposal is recommended/not recommended for
acceptance.l further undertake that I have caniad out requked verification and crmpleted the confidential report & encloeed with this
proposal form-

Date: I aii I r r Signature with Stamp:

Certifed that I have caretully examined ShrilSmt. the proponenl whose
signature/thumb impression is given below today the-- Day of _
On careful examination of the proponent and after going through the information furnished by him/her under column I &9, I find the proponent

to be medically fit. He/ She does not suffer from any terminal or other serious health hazard which would be risk to his/her life. I recommend
accaptance of his/her their proposal of Postal Life lnsurance policy.

The proponent is medically unfit. I do not recommend acceptance of his/her proposal for Postal Life Insurance policy.

$ignature of Modical Exarniner:

Signature of Proponent:

Date: I lti I -!:r }',


Note for Medical Officer

a) lf the proponent is overweight or has doubtful family history an electrocardiogram and a report on the scanning of the chest would
be required.
b) lf the proponent is under weight and has family history of TB, an X-Ray of the chest would be required.
c) Expense of the above-mentioned teste will have to be borne by the proponent.


Proposal No.
No. of Ll-7(a) Itl I ]Amount Deposilec l
n Prgmium:

,::i.ri",,o: i-,:..:
RPII salesperson/Agents procuring RPLI poliry will carefi.rlly check & veri{' the following
do.crrments before completing the Confidential Report in respect of each RPIJ proposal:

-. 'i. Age proof (seH-attested/thumb impressed copy of any of the following documents
:r L StandardAge proof (anyof the following documents)
a. Birth Certifleate
b. School Certificate/Mark sheet
c. PAN Card
d. Passport
e. Driving License
II. Non-StandardAgePnoof(arryofthefollowingdocuments)
a. AadharCard
b. Eider's declaration
c. Medical Examiner's approximate age certificate
d. Declaration by insurant eounter signed by Panchayat l4ember

ii. f;oJJ;'*5ir?-"oty proof (any of the followtns ao",r**r.t"l

a. AadharCard
b. Passprt
c. Driving License
d. Ration Card
e. Electricity Bill,/Water Bill

be completed by the RPLI Agent/Salesperson)

(This will consist of information not revealed in the proposal form. This will be completed by RPLI
Agent procuring poliry after proposal form is completed by proposer. Content of the record should
not be discussed with the proposer or divulged to him.)

r. Are you related to the propxrser? Yes No

2. Are yrru aware rrf any ffnancialTptry*icatTmental *ituatirrr+rncerning Y€ No
proposer which niakes him unsuitable for consideration of his Insuranee
g, In case of any doubt, please visit tle concerned police:st*tiodvillage
sarpanchhnd ved$if the poponent was ever*nested/convicted in the
eriminal case, If yes, give tletails
4. Has he signeifimpressed the proposafDeclaration form? Yes No
5, Any other rnatter yrxr wruild like kr bring tn the nrxiee af Propxal
Yes No
accepting authority.
6. Do you recommend the acceptance of the proposal? Yes No
7. If not remmmended, give reasons.

L Have 1ou mrrectly verified & checked fue proof (Non-standard)

prcduced byproposer Yes No
g.Have pu inquircd about general health condition of the proposer and
ccnfirm that he/she is uot suffcring &om rny serious/terminal illness. Yes
H No
ro.Has the requireel medical testsl examinationof the proposer been
carried out by authorised medical examiner and is found fir/unfit

rr.. Please confirm that: -

I No
(r) Confidential repofi has been n'ritteu by you after completion of l{ot
propqsal form by pmposer. : confirmed
(s) Coddestial regrrt has ntrt been divulgul to prupxrser/ <.riliscus$ql
with hin. : crrnfifiiied
Signature of RPLI Agent:

Full Name with Agent

code No.

Mobile No
Notes/Instructions for fiIling up the Froposal Forrn(Not to be scanned & uploaded)

1. Please provide valid proof of your age. In case youare not having any valid proof of d.ate of birth
you may produce any of the following documents (non standard age proof)* :

a. Self-declaration attested by Pancha;iat memberlgram Pradhan.

b. Medical offrcer's appropriate age certificate.

d. AadharCard
(*policy(ies) taken on non standard age proof will be charged S% additional premium)
2. Please mention your mobile number, email.IDat appropriate plaee. Mentioning mobile number
and email address will help us in sending SMS and e-mail alerts to you forvarious services of .

3. Nomination in Poliey will help in timely and hassle-fiee settlement of claim, if a policy becomes
a claim before date of maturity. Therefore, it is advisable to give nominee (s) details in eaeh

4. In case poliry is taken under Married Women PropertyAct 1874, nomination in such case is not
required. In such case name of the beneficiary (i.e. wife) should be mentioned at serl 4 @ of
proposal form
Mentioning Aadhar/ PAN is optional. However, it would faeilitate us to provide better after salm

In case of change of address/nomination, proponent is advised to notifr the same to nearest
CPC concerned.
In case, nominee is minor, partieulars of person as appointee should be given at appropriate
Please mentionyour BankAccount No. or Post OfHce Account, if any.
9. Willful concealment of anymaterial informationwill renderthe contractvoidable at anytime.
ro. Change of commtnication address, mqhile number or email address may be hrought to
information of Department to avail better after sales service.
rr. In case the proposer is illiterate the thumb impression of the pnoposer should be attested by a
percon of stand.ing whose identity can easily be established but unconnected with the Deptt. and.
this declaration should be made by him"