APPLICATION FOR REVIVAL OF PLI POLICY

1. Policy No. : _____________________________

Date of acceptance : _______________________

2. Name of Insurant ____________________________________

(In block letters)

3. Present address for _____________________________________

Correspondence

4. Date of maturity of the ______________________________________

Policy

5. Mode of payment of premia ______________________________________

6. Period for which premia ______________________________________

are due

7. Reason for non-payment ______________________________________

of premiums if any

8. Name of the Post Office ______________________________________

at which premia are

desired to be paid

I hereby declare that, I continue to be in good health since the date, the first unpaid premium had become due in respect of above mentioned policy till this date.

 Date : ___________________ Signature of Insurant

______________________________________________________________________________________

CERTIFICATE OF EMPLOYER

Certified that Shri/Smt._______________________________________________________

Had not taken any leave on medical grounds for the diseases like insanity, Epilepsy, Govt. Asthama, Tuberculousis, Cancer, Leprosy, Diabetes etc. as per medical certificate produced by him from time to time during the period from the date, the first unpaid premium had become due in respect of PLI Policy No.______________________________________ held by him till this date.

Date:

Signature of Employer

With designation stamp