(Established by the Life Insurance Corporation Act, 1956)

FORM OF NOMINATION ( Form No. 3264 )

I, the Assured under the within

Policy , hereby nominate under Section 39 of the Insurance Act 1938, my (relationship )

named aged years

and whose address is :

as the person to whom the moneys secured under this Policy shall be paid in the event of my
death .

Signed at , this day of 20 .

Witness :

______________________________ _______________________________

( Signature of Witness in English ) ( Signature of Life Assured )

Full Name : “Certified that the contents of the above

Nomination have been explained by me to
Designation : the Assured ……………………………… in
Vernacular and that he affixed his signature/
Address : thumb impression thereto in my presence,
after thoroughly understanding the same”.

_______________________________
( Signature of Witness )

( Seal )

( See Instructions)

Form of Nomination (Form 3264) Page 1 of 2