Form No.

3179-A (R)

Life Insurance Corporation of India

Place:………………….

Date:…………………

The Sr. Branch Manager,

Life Insurance Corporation of India,
Branch Office,

Dear sir,
Re: Proposal No…………………………………

With reference to my above proposal, I hereby agree to the

(1) imposition of clause 4(B) on account of sex

& / or

(2) the extra premium being charged at the rate of Rs…………………(Rupees……………………………

……………………………………………………………………………………………………………

per thousand sum assured per annum on account of

(a) occupation, viz………………………………………………………………………………………...

(b) physical condition, viz………………………………………………………………………………..

© other reasons, viz………………………………………………………………………………………

& / or

(3) exclusion / inclusion of …………………………………………………………………………………..

…………………………………………………………………………………………….

Yours faithfully,

(Proposor’s Signature)