DEPARTMENT OF POSTS

PROPOSAL FORM FOR POSTAL LIFE INSURANCE

1. Name in full in block letters : ____________________________

(Surname First)

2. Father’s/Husband’s Name : ____________________________

(In block letters)

3. Department/Organization : ____________________________

4. Present Official Address : ____________________________

____________________________

____________________________

5. Permanent Residential Address : ____________________________

____________________________

____________________________

PIN___________

6. Designation of Proponent : ____________________________

7. Date of entry in Service : Day Month Year

8. Address of Employer : ____________________________

____________________________

9. Sex : Male Female

10. Date of Birth : Day Month Year

11. Whether Policy is Medical : Yes No

12. Type of Policy proposed to be taken : ____________________________

13. Age of Maturity : ____________________________

14. Sum Assured : (In figures)___________________

( In words)___________________

15. Premium rate : ____________________________

16. Mode of Payment : Monthly Half yearly Yearly

(a) Cash : ____________________________

(Name of PO and Pin Code)

(b) Pay recovery : ____________________________

(Name of DDO and his Code by whom

Recovery of premium shall be effected)

: Name Age Relationship

17. Particulars of Nominee(s) 1__________|_________|_______

2__________|_________|________

3__________|_________|_________

18. Name of Guardian /Appointee if Nominee(s) Name Age Relationship

is/are minor with Nominee

1_________|_________|__________

2_________|_________|__________

3_________|_________|__________

19. Particulars of other PLI/RPLI policies already held :

S.N. PLI/RPLI Policy No. Sum Assured

1.

2.

3.

4.

20. (a) Are you in sound health at present? : ____________________________

(b) Have you ever suffered/suffering from any of the following?:

(Say Yes or No)

(i) Tuberculosis : Yes No

(ii) Cancer : Yes No

(iii) Paralysis : Yes No

(iv) Insanity : Yes No

(v) Any disease of hear and lungs Yes No

(vi) Kidney disease: Yes No

(vii) Any disease of brain Yes No

(viii) Diabetes : Yes No

(ix) Hypertension : Yes No

(x) HIV Positive : Yes No

(xi) Hepatitis-B : Yes No

(xii) Epilepsy : Yes No

(xiii) Nervous disorder Yes No

(xiv) Liver : Yes No

(xv) Leprosy : Yes No

(xvi) Any physical deformity or handicap Yes No

(xvii) Any other serious disease Yes No

(c) Has any of your family member (Father, Mother, Brothers or Sisters) living or dead suffered from any hereditary or infectious disease like, Insanity Epilepsy/Gout/Asthama/Tuberculosis/Cancer/Leprosy/Diabetes etc. if yes, give details:

Yes No

(d) Have you availed of any kind of leave on Medical ground or hospitalized during the last 3 years? If so, furnish the following information:

__________________________________________________________________

Kind of leave Period of leave Ailment Name of Hospital Period of Hospitalization

From To

1.

2.

3.

4.

5.

(e) Particulars of the family doctor, if any: ___________________________

21. DECLARATION OF PROPONENT

I do hereby declare that (I) No proposal of insurance on my life has ever been adversely treated (II) the foregoing statements made are true to the best of my knowledge and belief (III) in case it is found that 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 premia which shall have been paid by me, shall be forfeited and this contract rendered absolutely null and void (IV) I understand that my life shall be insured from the date , my proposal is accepted (V) I have gone through the terms and conditions for insurance with PLI and a copy of which has been given to me. I hereby agree to abide by them.

Date

Signature

Place

22. CERTIFICATE OF IMMEDIATE SUPERIOR

Certified that _________________________________ is a permanent/temporary employee in _________________________________________ and information furnished against column No. 1 to 10 of this proposal form is correct as per his/her service records.

Date Signature

Place Name

Designation/Seal

23. MEDICAL EXAMINER’S CERTIFICATE

Certified that I have carefully examined ______________________________ the proponent whose signature is given below today the __________________ day of _______________ 2001.

On careful examination of the proponent and after going through the information furnished by him/her under column 20, 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 acceptance of his/her proposal for Postal Life Insurance policy.

OR

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

Signature of Proponent

Signature

Name

Seal

Doctor’s Code

NOTE FOR MEDICAL OFFICER:

1. When there are two or more cases of diabetes in the family, report of Glucose Tolerance Test and Urine would be required and if the proponent is over weight in addition to the family history of diabetes or there is a suspicion of sugar in the urine or personal history of glyucosuria, a blood sugar report would be necessary.

2. If the proponent is over weight or has doubtful family history an electrocardiogram and a report on the scanning of the chest would be required.

3. If the proponent is under weight and has family history of TB an X-Ray of the chest would be required.

4. Expense of the above mentioned tests will have to be borne by the proponent.

24. TO BE FILLED IN BY DO/FO (PLI)

Type __________________________ Sum Assured _______________________

Age at entry ____________________ Premium rate _______________________

Receipt (LI-7(a) No. _____________ Date ___________ Amount ____________

Name of Medical Officer _____________________________________________

Code No. of Medical Officer __________________________________________

Post Office where payment is to be made_________________________________

I ___________________________________ Code No. _______________

Certify that the information in the proposal form has been furnished by the proponent in my presence. All columns have been completed and are correct and no question is left un-answered. The proposal is recommended for acceptance.

SIGNATURE

DATE

25. CERTIFICATE OF DDM/ADM (PLI) IN RESPECT OF PROPOSAL RECEIVED FROM D.O.

Certified that the entries against column No. 1 to 19 & 21 have been verified by me and found in order. The proposal is accepted.

The proposal is rejected due to the following reasons

1.

2.

3.

PA/SS

DATE

ADM/DDM