DIRECTORATE OF INSURANCE

GOVERNMENT OF ANDHRA PRADESH, HYDERABAD

Policy No. REGIONAL OFFICE

NELLORE

PROPOSAL FOR INSURANCE ON OWN LIFE

(Answers should be given clearly, strokes of the pen or dashes, etc., will not be
accepted as replies)

1. a) Name in Full
(in BLOCK LETTERS)
b) Father’s Name in Full
c) Designation
2. Date of Birth
Place of Birth
3. Married/Unmarried/Widowed
4. Details of service in State
Government
a) Date of first appointment
b) Substantive Post held (if any)
Pay Rs.
Scale Rs. –
c) Present Post
Pay Rs.
Scale
d) Temporary or Permanent
5. If already insured with the Policy No./Nos. Monthly Premium
DIRECTORATE OF INSURANCE

Proposed Monthly Premium

6. Name of the Nominee(s) and
Father’s Name in full
Relationship Age Share
7. Has any proposal on your life or an
application for revival made to any
office of P.L.I. or L.I.C.I. or this
office ever been:
a) Withdrawn or Dropped?
b) Rejected or Postponed?
c) Accepted with extra/loading/
lien?
d) Accepted on terms otherwise
than as proposed?
8. FAMILY HISTORY
LIVING DEAD
of illness

Cause of
Duration

State of Health (if

Family History Age
Year of

Age at
Death

Death

Death

not good, give

Years
details)

FATHER

MOTHER
 Brothers No.:
(Excluding Proponent)
Total Living:
Total Dead :
Sisters No.:
(Excluding Proponent)
Total Living:
Total Dead :

Wife / Husband

Children No.:
(Excluding Proponent)
Total Living:
Total Dead :
9. a) Have any of your relations
living or dead, suffered from
insanity, epilepsy, gout,
asthma, tuberculosis, cancer,
leprosy, diabetes, haemophilia
or any other hereditary
disease? If so, give details
b) Have you lived during the last
3 years with any person
suffering from tuberculosis,
leprosy or any other
communicable disease? If so,
give details
10 a) Are you now in good health? If
not, give details.
b) Are you now absent from duty
on the grounds of ill-health?
c) Are you applying for leave on
the grounds of ill-health?
11 Have you ever been in a clinic,
isyium or sanatorium for X-Ray,
electrocardiogram, check up,
observation, blood test, fluroscopic
examination, treatment or
operation? Give details, if any.
12 a) Do you use or have you ever
used Alcoholic Drinks, Bhang,
Ganja, Opium or any other
narcotic drug? If so, give
details.
b) Are you addicted to the use of
any Drug?
13 a) Have you had small pox? If so,
when?
b) Have you been vaccinated
successfully against small pox?
If so, when were you last
vaccinated?
14 a) Have you ever passed blood,
pus, albumen, or sugar, in the
Urine?
 b) Are you suffering from any
kind of Hernia? If so, do you
wear a truss regularly?
c) Are any of your teeth lost or
extracted?
d) Are you suffering from
Pyorthoess?
15 Have you ever sufferred from any YES / NO
of the following diseases?
If yes, describe fully each ailment giving
it's nature, number of attacks, dates,
duration, severity, treatment taken,
result and names and addresses of
doctor consulted.
a) Giddiness, fits, neurasthenia,
neuralgia, paralysis, insanity,
nervous break down; or any
other of the brain or the
nervous system?
b) Persistent cough, asthma,
pneumonia, pleurisy, spitting
of blood, tuberculosis or any
other diseases of the lungs?
c) Fainting attacks, pain in chest,
breathlessness, palpitation or
any disease of the Heart?
d) Sprue lanndice Anemia, Piles,
Dysentery, and Cholera,
Abdominal pain, Appendicitis or
any disease of the stomach,
liver, spleen or intestines?
e) Any skin erruation?
f) Hernia, Hydracele, Varicocele,
Fistula or Varicose Veins?
g) Any disease of the Kidney or
Bladder, Dropsy, Rheumatism,
gout gonorrhea, syphilis or any
other venereal diseases?
h) Cancer or Leprosy?
i) Any disease of the ear, nose,
throat or eyes, including
defective eyesight or hearing?
j) Malaria, Typhoid, Influenza,
Kaja Azar Filariasia or any
other fever lasting for more
than a week?
k) Any other illness within the last
five years?
l) Any physical disease or
deformity?
FOR WOMEN
a) Have your menstrual periods
always been regular and
painless and are they so now?
b) How many conceptions have
 taken place?
c) How many have gone full time?
d) State the date of last
menstruation
e) State the last date of delivery
f) Are you pregnant now?
g) Have you had any abortions or
miscarriages? If so, how many?
State the date of last abortion.
h) Have you suffered from any
disease of the breast, ovary or
uterus?
i) Have you suffered from
weakness or injury resulting
from child bearing or
miscarriage?

DECLARATION BY THE PROPONENT

“I do hereby declare that the foregoing statements and answers have been
given by me after fully understanding the questions. The same are true, full and
complete. Whether written by my own hand or not in eye particular and that I
have not withheld or concealed any circumstances with regard to which
information has been required from me. I agree that the foregoing statements and
this declaration shall be the basis of the proposed contract for an insurance and
that, and any circumstance which I ought to have made known then all the premia
which shall have been paid under the said contract shall be forfeited and the
contract rendered absolutely null and void.”

“Not withstanding the provision of any law usage customs or convention for
the time being in force, prohibiting any physician from divulging any knowledge of
information acquired by him in attending upon or examining a person, I, my heirs,
executors, administrators and assigns or any other person or persons who shall
have claim or interest of any kind, whatsoever in the policy issued on the basis of
foregoing answers hereby agree that any physical or medical attendant who has
attended upon or examined, treated me or who may hereafter attend, examine or
treat me for any ailment or illness shall be at liberty to divulge any knowledge or
information regarding my state of health, he may have acquired whether before or
after the policy is issued by the Regional Offices of Directorate of Insurance to the
Directorate of Insurance and Legal advisors or in a Court of Law.”

“And I further declare that in case this proposal is accepted by the

Directorate of Insurance, a letter of acceptance, issued to me and in case any
adverse circumstance connected with the general health of myself, however
unimportant, I may consider the same, has occurred or occur between the date of
this proposal and the date of payment of this first premium in full if a proposal for
assurance or any application for revival of a policy on my life made to any office of
the Life Insurance Corporation of India to the Post Office Insurance Fund has since
the date of this proposal been withdrawn or to be dropped, deferred or disclaimed,
or accepted at an increase premium or subject to a lien, the assurance will be
invalid and all moneys which shall have been paid in respect thereof forfeited
unless intimation of such event be made in writing to the Regional Offices of the
Directorate of Insurance and the acceptance of the proposal shall be reapproved
by the concerned Regional Office.”
Date: Signature of the person whose Life is
proposed to be assured

CERTIFICATE BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

I certify that the service particulars stated above are correct and the
proponent’s signature has been affixed in my presence.

Station: Signature
Date: Designation