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Life Insurance Corporation of India
IPR-F300-V1.0
Recent Passport Size Photo
(Established by the Life Insurance Corporation Act, 1956)
FORM NO. 300 (Rev. 98 ) PROPOSAL FOR INSURANCE ON OWN LIFE
(Not to be used on the lives of Minors)
Inward Number:
Date.
Reset Form
Branch Office Code: Satl Branch Code:
000000
FOR OFFICE USE ONLY : Proposal no : Amt of Deposit : B.O.C No. Date :
To be filled in by Agent: Division Code: 000
Agent’s Name: Agent’s Code : Ag .License No. Proposal. Dt : Dev. Officer Code: Date of Expiry Medical Code : :
0000000
(All answers to be filled in legibly. Answers must be given in Words. Stroke of the pen or dot or dashes will not be accepted as replies. )
Title:
Surname:
Initial:
Object of Insurance :
Full name (Surname first) and address to which communication are to be sent. Addr1: Addr2: Nationality : Addr3:
000000 Pin: Tel Nos (with:STD Code):Res: 2A Residential address, if different from above : Addr1:
Place of Birth :
Sex :
Off:
Click to Copy ...
Nature of Age-Proof submitted:
Addr2: Addr3: Pin: e-mail: Short Name : Father’s Full name (Surname First )
Copy ...
Age (nearer birthday)
000000
Date of Birth
Yrs.
2B. Nominee’s Full name(Surname first) and address Name : Addr1: Addr2: Addr3: Pin :
Age
Relationship to yourself
Title Code
Yrs. Age Relationship to nominee Signature of Appointee as token of consent
If Nominee is a minor, appointee’s full name and address Name : Addr1: Addr2: Addr3:
Yrs. Pin :
Note: It is in the interest of the Proposer to avail the facility of nomination
We Know India Better
Page 1 of 6
Life Insurance Corporation of India 3
Plan
Policy Term
IPR-F300-V1.0
Date of Commencement. If policy is to be dated back indicate that date .
Premium Term
Sum Proposed (Rs.)
Term rider sum proposed (if required)
Is accident Benefit required?
Total Amount Deposited (Rs. )
Critical illness sum proposed
IPR-F300-V1.0
Recent Passport Size Photo
(Established by the Life Insurance Corporation Act, 1956)
FORM NO. 300 (Rev. 98 ) PROPOSAL FOR INSURANCE ON OWN LIFE
(Not to be used on the lives of Minors)
Inward Number:
Date.
Reset Form
Branch Office Code: Satl Branch Code:
000000
FOR OFFICE USE ONLY : Proposal no : Amt of Deposit : B.O.C No. Date :
To be filled in by Agent: Division Code: 000
Agent’s Name: Agent’s Code : Ag .License No. Proposal. Dt : Dev. Officer Code: Date of Expiry Medical Code : :
0000000
(All answers to be filled in legibly. Answers must be given in Words. Stroke of the pen or dot or dashes will not be accepted as replies. )
Title:
Surname:
Initial:
Object of Insurance :
Full name (Surname first) and address to which communication are to be sent. Addr1: Addr2: Nationality : Addr3:
000000 Pin: Tel Nos (with:STD Code):Res: 2A Residential address, if different from above : Addr1:
Place of Birth :
Sex :
Off:
Click to Copy ...
Nature of Age-Proof submitted:
Addr2: Addr3: Pin: e-mail: Short Name : Father’s Full name (Surname First )
Copy ...
Age (nearer birthday)
000000
Date of Birth
Yrs.
2B. Nominee’s Full name(Surname first) and address Name : Addr1: Addr2: Addr3: Pin :
Age
Relationship to yourself
Title Code
Yrs. Age Relationship to nominee Signature of Appointee as token of consent
If Nominee is a minor, appointee’s full name and address Name : Addr1: Addr2: Addr3:
Yrs. Pin :
Note: It is in the interest of the Proposer to avail the facility of nomination
We Know India Better
Page 1 of 6
Life Insurance Corporation of India 3
Plan
Policy Term
IPR-F300-V1.0
Date of Commencement. If policy is to be dated back indicate that date .
Premium Term
Sum Proposed (Rs.)
Term rider sum proposed (if required)
Is accident Benefit required?
Total Amount Deposited (Rs. )
Critical illness sum proposed