Chandrashekhar LIC 1193406093228forms

PROPOSAL FORM
Plan Name LIC's e – T e r m Plan Number 825 UIN 512N288V01

Proposal No. Proposal Date Recent passport size
Recent Passport Size
Access_Id photograph
Photo of theofLife
119340609 Mobile No. * 9167375720
Assured
the proposer
Email Id csdubey009@gmail.com
User_Id
✔ * I hereby confirm that the mobile number provided by me, is registered in my own name. By ticking this box,
I hereby authorize Life Insurance Corporation of India to verify the above information and call me back
even if I am registered in the Do not call List of TRAI.
▼ Details of plan proposed
Term Sum Assured Premium Mode of Payment Category

20 8000000 0 Yearly Non-Smoker Rate

✔ I undertake to undergo all the medical tests as may be prescribed / required by the Corporation for the grant of insurance.
▼ Personal details of the life to be insured
1. Title Mr 2. Short Name CHANDRASHEKHAR 3. Gender ✔ Male Female Third Gender
4(a). First Name Chandrashekhar
4(b). Middle Name R
4(c). Last Name Dubey
5. Father's Name Rishideo
6. Qualification Graduate+Diploma 7(a). Date of birth 01-07-1981 7(b). Age 37
8. Age Proof School Certificate 9. Place of birth Ballia
10. Marital Status Married 11. Purpose of Insurance Protection
▼ Communication details
12 (a). Present Address for communication 12(b). Permanent Residential Address
Address Line-1 flat no 204, c wing, shreenath nagar Address Line-1 flat no 204, c wing, shreenath nagar
Line-2 chsl Behind Gokul anad hotel Dahisar Line-2 chsl Behind Gokul anad hotel Dahisar
Line-3 east Shivvallabh road, Ashokvan Mumbai Line-3 east Shivvallabh road, Ashokvan Mumbai
PIN Code 400068 PIN Code 400068
Phone (Landline) null Phone (Landline) null
▼ Identification particulars
13. Citizen / Residential Status 

✔ I am an Indian citizen ✔ I am Indian Resident I am NRI
14. Address Proof Aadhar Card
15. Identification Proof Aadhaar Number
16. PAN AILPD3802G
12-08-2018 19:45:21 eTerm:: LIC's Online Term Insurance Page 1 of 6

Proposal Form
▼ Employment details of the life to be insured
17. Occupation Others 18. Nature of work Field work (travelling)with some
desk job
19. Name of present employer Harmonny Life Science Pvt Ltd 20. Length of service 17
21. Annual income 1320000 22. Source of income Salary
23. Does your occupation involve working with any of the following?
Hazardous chemicals Hazardous materials Nuclear reactive substance
Arms Ammunitions Explosives

Mines Heights above 50 feet Under water below 30 feet
High speed rotary machines or Involves frequent international travel by air/ road/ rail/ water,
equipment/conveyor belts more than 6 trips a year
✔ None of these
24. Does your job involve travelling outside India to countries other than North America, Western Europe, Yes ✔ No
Russia, China, Japan, Korea, Hongkong, Singapore, Australia, New Zealand, Mauritius, Sri Lanka,
Bangladesh, Nepal, Bhutan, Denmark, Norway, Sweden, Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, UAE
and involving stay for a period greater than 3 months in a year
25. Are you employed in armed forces? Yes ✔ No

(If your answer is 'Yes', please provide the following details:
(a) Wing to which you (b) Date of last medical

belong? examination
(c) Rank therein (d) Medical category after

medical exam
(e) Were you ever (f) If yes, when.

below A-1 category? (please provide date)
▼ Lifestyle details
26. Do you use or have you ever used Tobacco in any form? Yes ✔ No
If yes, cigarette smoked per day Less than 5 Less than 10 10 or more
27. Do you use or have you ever used Alcoholic drinks? Yes ✔ No
If yes, units consumed per day Less than 30ml Less than 60ml 60ml or more
28. Do you use or have you ever used Narcotics in any form? Yes ✔ No
If yes, specify in which form used
29. Do you use or have you ever used any other type of drugs? Yes ✔ No
If yes, specify the type of drug used
30. What has been your usual state of health? ✔ Good Not Good
If 'Not Good', please mention the health issues
31. Have you ever been or are currently being investigated, Yes ✔ No
chargesheeted, prosecuted or convicted in respect of any
criminal/civil offences in any court of law of India or abroad?

Proposal Form
▼ Nominee / Appointee details
32. Particulars of Nominee
Name SEEMA C DUBEY

Relationship to the proposer Wife
Age 32
Address Line-1 flat no 204, c wing, shreenath nagar
Line-2 chsl Behind Gokul anad hotel Dahisar
Line-3 east Shivvallabh road, Ashokvan Mumbai
PIN Code 400068
33. Particulars of Appointee (required when the nominee is minor)
Name
Relationship to the nominee
Age 0
Address Line-1
Line-2
Line-3
PIN Code
▼ Details of previous policies held / proposals applied
34. For list of previous policies, please see annexure
35. Is your life now being proposed for another assurance or an application for revival Yes ✔ No
of a policy on your life or any other proposal under consideration in any office of
Life Insurance Corporation of India or to any other insurer?
If yes, please give details
36. Has a proposal (or an application for revival of a policy) on your life made to any office of Life Insurance Corporation
of India or to any other insurer ever been:
(a) Withdrawn, Deferred, Dropped or Declined? Yes ✔ No

(b) Accepted with extra Premium or Lien? Yes ✔ No

(c) Accepted on terms otherwise than those proposed? Yes ✔ No
(d) Have you during past one year returned any policy of Life Insurance Corporation of Yes ✔ No
India as the same was not acceptable to you?

Proposal Form
▼ Medical details of the life to be insured
37. Height (in cms) 170 38. Weight (in kgs) 68
39. During the last five years did you consult a Medical Practitioner for any ailment requiring Yes ✔ No
treatment for more than a week ?
40. Have you ever been admitted to any hospital or nursing home for general check up, Yes ✔ No
observation, treatment or operation?
41. Have you remained absent from place of work on grounds of health during the last 5 years ? Yes ✔ No
42. Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Yes ✔ No
Heart, Lungs , Kidney, Brain or Nervous System ?
43. Are you suffering from or have ever suffered from Diabetes, Tuberculosis, High Blood Yes ✔ No
Pressure, Low Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or
any other disease ?
44. Did you ever have any bodily defect or deformity ? Yes ✔ No
45. Did you ever have any accident or injury? Yes ✔ No

46. Have you or your partner ever required or at present availing/undergoing medical advice, Yes ✔ No
treatment or tests in connection with hepatitis B or AIDS related condition?
47. Are you currently suffering from any illness,impairment or taking any medication or pills or Yes ✔ No
drugs?
48. Do you take part in any hobbies / activities that could be considered dangerous in any way ? Yes ✔ No
e.g. aviation (other than as a fare paying passenger),mountaineering,diving or
any form of racing etc?
▼ Family history
Please refer to annexure “Family History”
▼ Female Life
Please refer to annexure “Female Life”
▼ Bank details of the life to be insured
49. Your bank account type ✔ Savings Current 50. Account Number 33619018388
51. IFS Code SBIN0016719 52. Bank Name STATE BANK OF INDIA
53. Bank Address UNIT NO. 26, A,B,C,D IN H WING, ADINATH TOWER, NANCY COLONY, BORIVALI EAST,
DISTT.MUMBAI. MAHARASHTRA 400066

Proposal Form
▼ Declaration of the life to be insured

Chandrashekhar R Dubey
I, ...................................................................................................................... the person whose life is herein being proposed to be
assured, do hereby declare that the forgoing statements and answers have been given by me after fully understanding the
questions and the same are true and complete in every particular 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
Life Insurance Corporation of India and that if any untrue averment be contained therein the said contract shall be absolutely null
and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation and nothing shall
be payable subject to section 45 of Insurance Act, 1938.
Not-withstanding 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 employment on the grounds of
secrecy, I, my heirs, executors, administrators and assignees or any other person or persons, having interest of any kind
whatsoever in the policy contract issued to me, hereby agrees that such authority , having such knowledge or information, shall at
any time be at liberty to divulge any such knowledge or information to the Corporation.
And I further agree that if after the date of submission of the proposal but before the issue of First Premium Receipt
(i) any change in my occupation or any adverse circumstances connected with my financial position or the general health of
myself or that of any members of my family occurs or
(ii) if a proposal for assurance or any application for revival of a policy on my life made to any office of the Corporation or any
other insurer has been withdrawn or dropped, deferred or accepted at an increased premium or subject to a lien or on terms other
then as proposed I shall forthwith intimate the same to the Corporation 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 thereof shall stand forfeited to the Corporation.
▼ Summary of Section 45 of Insurance Act, 1938

(1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date
of the policy, i.e., from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or
the date of the rider to the policy, whichever is later.
(2) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the
date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the
ground of fraud:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or
assignees of the insured the grounds and materials on which such decision is based.
Explanation I. For the purposes of this sub-section, the expression "fraud" means any of the following acts committed by the
insured or by his agent, with intent to deceive the insurer or to induce the insurer to issue a life insurance policy:
(a) the suggestion, as a fact of that which is not true and which the insured does not believe to be true;
(b) the active concealment of a fact by the insured having knowledge or belief of the fact;
(c) any other act fitted to deceive; and
(d) any such act or omission as the law specially declares to be fraudulent.
Explanation II. Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless the
circumstances of the case are such that regard being had to them, it is the duty of the insured or his agent keeping silence, to
speak, or unless his silence is, in itself, equivalent to speak.
(3) Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the ground of fraud
if the insured can prove that the misstatement of or suppression of a material fact was true to the best of his knowledge and belief
or that there was no deliberate intention to suppress the fact or that such misstatement of or suppression of a material fact are
within the knowledge of the insurer:
Provided that in case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
Explanation. A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the formation of the
contract, to be the agent of the insurer.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the
date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the
ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in
the proposal or other document on the basis of which the policy was issued or revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or
assignees of the insured the grounds and materials on which such decision to repudiate the policy of life insurance is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not
on the ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the insured or the legal
representatives or nominees or assignees of the insured within a period of ninety days from the date of such repudiation.
Explanation.For the purposes of this sub-section, the misstatement of or suppression of fact shall not be considered material
unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show that had the insurer been
aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy
shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of
the life insured was incorrectly stated in the proposal.
eTerm:: LIC's Online Term Insurance Page 5 of 6

Proposal Form
▼ Summary of Section 41 of Insurance Act, 1938

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or
continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the
commission payable or any other rebate of the premium shown on the policy, nor shall any person taking out or renewing or
continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or
tables of the insurer: Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance
taken out by himself on his own life shall not be deemed to be acceptance of rebate of premium within the meaning of this sub-
section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bonafide
insurance agent employed by the insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to ten
lakh rupees.

✔ I have read the declaration and summary of Section 41 and Section 45 of Insurance Act, 1938 and agree with the terms and conditions.
Signature of witness
Witness should be a third party (Not related to the life to be insured)
Name
Address
Signature of the life to be insured
Date:
Pin Code Place:
eTerm:: LIC's Online Term Insurance Page 6 of 6

PERSONAL FINANCIAL QUESTIONNAIRE (Annexure – I)
Access Id : 119340609
▼ Please give details of your personal income for the latest 2 years
-------- in Rs. on annual basis --------
Latest Year Prior Year
► Annual Salary 1320000.00 1050000.00
► Share from business profit 0.00 0.00
► Share of the Business (in %) 0.00 0.00
► Rental Income 0.00 0.00
► Investment income (equity / MF/ Bank Int. etc) 0.00 0.00
► Dividend Income 0.00 0.00
► Others including Agriculture, Minor's income 0.00 0.00
▼ What would be the value of your assets and liabilities?
( in Rs. )
► House(s) & immovable property including Land 0.00
► Investments (Equity / Mutual Fund / Bonds / Bank FDs / Post office / etc) 0.00
► Owned Vehicle 0.00
► Current Loans (if any) 0.00
► Other liabilities 0.00

GENERAL OCCUPATION QUESTIONNAIRE (Annexure – IV)
Access Id : 119340609
Full name of the Employer Harmony Life Science Pvt Ltd
Department in which you work Sales
Your designation or occupation Zonal Salas Manager
Full details of the nature of your duties Sales & Marketing
If you are supervisor, nature or work done under your supervision Sales
1. Construction Workers:
(a) Are you engaged in scaffolder / steel erector activity ? Yes ✔ No
(b) Are you a painter - exterior ? Yes ✔ No
2. Drivers:
(a) Do you drive public carriers (goods / passenger vehicles) ? Yes ✔ No

Yes ✔ No
(b) Do you hold national driving permit ?
3. Manufacturing:
(a) Acids - Are you a lead burner working in vats or chambers ? Yes ✔ No
Explosive & Ammunition - Are you employed in salvage and Yes ✔ No

(b)
reconditioning department ?
4. Tunnelling
Are you air compressor operator, Civil engineer, Engineering Yes ✔ No

(a)
geologist, Structural engineer ?
Are you dumper shovel driver / Foreman (above ground) / Yes ✔ No

(b)
Mechanical shovel driver /Winch driver ?
Are you conveyor operator /Foreman (below ground ) /Manhole Yes ✔ No

(c)
maker /Power loader operator /Roof bolter /Timberman ?
Are you Borer /Driller /Tunnel miner (no explosives) / Tunneller Yes ✔ No
(d)
(no explosives) ?
Are you Shotfirer /Tunnel miner (using explosives) / Tunnel Yes ✔ No

(e)
miner's labourer /Tunneller (using explosives) ?

GENERAL OCCUPATION QUESTIONNAIRE (Annexure – IV)
5. Mining Industry
(a) Type of mine
Whether you work underground ? and average Yes ✔ No 0

(b)
number of hours spent underground per week
(c) Are you an underground rescue worker ? Yes ✔ No
6. Motor Cycle Sport -Circuit Racing
Do you take part in motor cycle circuit racing - Yes ✔ No

(a)
(closed, restricted or national events) ?
(b) What is the engine capacity of the motor cycle ? 0
(c) Number of events per annum ? 0
(d) Do you take part in international events ? Yes ✔ No
7. Oil & Natural Gas Industry
Are you based offshore or do you expect to be based

(a)
offshore in future
(b) Do your duties involve underwater work ? Yes ✔ No
(c) Do your duties involve working at heights ? Yes ✔ No
(d) Do you ever travel to and from rigs by helicopter ? Yes ✔ No
Can your occupation be described as: Drilling Yes ✔ No

assistant, Fire fighter, connection mechanic, crane
(e)
operator, Top-man, Rigman, Derrickman, Roughneck,
roustabout (not handling explosives)s ?
8. Sewers & Sewage Disposals
Are you a labourer, Cleaner, inspector of underground Yes ✔ No

(a)
duties ?

PREVIOUS POLICIES ANNEXURE
Access Id : 119340609
Sum Commence- How

Policy No. Insurer Plan Premium Status
Assured ment Date Accepted
NIL NA NA NA NA 0 NA NA

FAMILY HISTORY
Access Id : 119340609
Relationship Living / Present State of Health Age at Cause of Death

Dead Age Death
Daughter 12 Good 0
Mother 62 Good 0
Wife 32 Good 0
Daughter 10 Good 0
Father 67 Good 0

e-KYC DETAILS FROM UIDAI
Access Id : 119340609
▼ Personal Details
Aadhaar No. / Virtual ID : XXXXXXXX8873
Name :` Chandrashekhar R Dubey Photo
1981-07-01
Date of Birth : Gender : M
▼ Contact Details
C/o.
flat no 204, c wing, shreenath nagar chsl

House / Bldg. / Apt.
Shivvallabh road, Ashokvan

Street / Road / Lane
Behind Gokul anad hotel

Landmark
Dahisar east
Area / Locality / Sector
400068
Pincode
Mumbai
Village / Town / City
Mumbai
P.O.
Mumbai
District
Maharashtra
State
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PROPOSAL FORM

Plan Name LIC's e – T e r m Plan Number 825 UIN 512N288V01

▼ Details of plan proposed

Term Sum Assured Premium Mode of Payment Category

▼ Personal details of the life to be insured

1. Title Mr 2. Short Name CHANDRASHEKHAR 3. Gender ✔ Male Female Third Gender

4(a). First Name Chandrashekhar

4(b). Middle Name R

4(c). Last Name Dubey

5. Father's Name Rishideo

6. Qualification Graduate+Diploma 7(a). Date of birth 01-07-1981 7(b). Age 37

8. Age Proof School Certificate 9. Place of birth Ballia

10. Marital Status Married 11. Purpose of Insurance Protection

12 (a). Present Address for communication 12(b). Permanent Residential Address

PIN Code 400068 PIN Code 400068

Phone (Landline) null Phone (Landline) null

13. Citizen / Residential Status 

14. Address Proof Aadhar Card

15. Identification Proof Aadhaar Number

16. PAN AILPD3802G

12-08-2018 19:45:21 eTerm:: LIC's Online Term Insurance Page 1 of 6

▼ Employment details of the life to be insured

21. Annual income 1320000 22. Source of income Salary

Hazardous chemicals Hazardous materials Nuclear reactive substance

Arms Ammunitions Explosives

25. Are you employed in armed forces? Yes ✔ No

(a) Wing to which you (b) Date of last medical

(c) Rank therein (d) Medical category after

(e) Were you ever (f) If yes, when.

If 'Not Good', please mention the health issues

12-08-2018 19:45:21 eTerm:: LIC's Online Term Insurance Page 2 of 6

▼ Nominee / Appointee details

32. Particulars of Nominee

Name SEEMA C DUBEY

PIN Code 400068

33. Particulars of Appointee (required when the nominee is minor)

Relationship to the nominee

▼ Details of previous policies held / proposals applied

34. For list of previous policies, please see annexure

If yes, please give details

(a) Withdrawn, Deferred, Dropped or Declined? Yes ✔ No

(b) Accepted with extra Premium or Lien? Yes ✔ No

(c) Accepted on terms otherwise than those proposed? Yes ✔ No

If yes, please give details

If yes, please give details

12-08-2018 19:45:21 eTerm:: LIC's Online Term Insurance Page 3 of 6

▼ Medical details of the life to be insured

37. Height (in cms) 170 38. Weight (in kgs) 68

If yes, please give details

If yes, please give details

If yes, please give details

If yes, please give details

45. Did you ever have any accident or injury? Yes ✔ No

If yes, please give details

If yes, please give details

If yes, please give details

▼ Bank details of the life to be insured

12-08-2018 19:45:21 eTerm:: LIC's Online Term Insurance Page 4 of 6

▼ Declaration of the life to be insured

▼ Summary of Section 45 of Insurance Act, 1938

eTerm:: LIC's Online Term Insurance Page 5 of 6

▼ Summary of Section 41 of Insurance Act, 1938

Pin Code Place: