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DEPARTI,IENT OF POSTS
FoR RURAL PosrAL LIFE INSURAN.E (RPLI)
(Altentries.houtd be o,,.o,r.i#fo???t:)FoRM
AgenUAdvis;r Code:.
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i. Name of Proponent flMr. DMrs. fl lvts.1
Yes I lNo
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iCorrespondence Address
Tick here if permanent address is same ({}
Correspondence Address: Permanent Address:
Village/Locality; Village/Locality:
Post Office: Taluka/District: _ Post Office: Taluka/District: _
State: Pincode: State: Pincode:
Mobile No: Mobile No:
Email address: (if anv) Email address: (if anv)
Occupation:
ulonthly lncome
t,
,,
,b. Appointee D_etails (lf nominee is minor)
C. Particulars of beneficiary(ies), if policy is taken under Married Wornen Property Act 1874, (nomination in such cases are not
allowed).
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Premium
i. ii. lnitial Premium Payment Mode iii. Subsequent Premium Payment ModeCash I Online
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iv. Premium Payment Frequency MonthU [--l Quarterly f_l HalfYearty [-*l YearU f'l
High blood pressure, angina" heafi attacl( stroke or any other disorder of heart or circulation?
Mental or nervous illness (including depression) lasting for more than 3 months and/or requiring more than 10
consecutive days off work?
Not*ith.,t.n4,nn tho provision of any law, u6age, curtom or convontion for the time boing in forc6 prolribiting any doctor, hosFital and/or enrploysr from
divulging ai7 knoliledge or information about me concaming my health or on the grounds of secr€cy I, my heirs nominae, exocutors, administrators and
aeelglnels oi any other-persons or persons having intorest of any kind whateoevar in tho policy contraot issued to_ m6, horeby agrBe, that such authority, having
suct kno,vledgsor information shall at any time b€ at liberty to divulge any such kno^rledge or information to the Deparhlent.
And I further agree that if after the date of the submission of ths propGel but bsforo the acceptanc€ of tho proposal, (i) any change in my occupetion any
adverse circumstance connected with my financial preition or the gen€ral hoalth of my.etf or that of any m€mber of my family occurs or (ii) if a propoeal for
assurance or an applbation for rovival of a policy on my lif6 made to any offics of the Oepartnent has boen withdrawn or dropped, dsfened or declined or
accepted at an inorease premium or subjoct to a lien or a tEm other than as propo€Ed, I Shall fortlwith ifiimate the samq to the Dbparfrent in writng to
reconsidEr the terms of acc€ptance of e66urance. Any omtssion on my part to do €o shall ronder this assurance invalld and all moneys \,vfiich 6hall havB boen
paid in respect thereof forfeited to the Department.
gbide by
al The contents of surrend6r table and instructions for admissibility of surrender vaiue have been explained to me before taking policy and t
thesame-
b) Surrender of a policy b not admiGsible before completion of thirty-six months of the policy and tho amour* doposited shall be forfoned il I
-
i.t am not suffering from Hypsrtension & Diabate6 and not taking any tBaunent for Hypertension &
Diabetes.
OR
t have been suffering from Diabetes/Hyp€rtension from the last yoarc but with proper medical adice & medication it is with in control
and no complication has surfaced so far pooing any threat to my life.
|-herebyegreetopaythefeeoft-(perindividuaI)forthemedicalexaminationifmypropoealie
not accepted.
- been explained about the featuroa of the product and I believe, it would be suitable
The above reoommondation is based on the information provided byme. I hav€
for me based on my insurance needs and financial objectives.
Proponent's Signature /
Thumb lmpression {*f<.
(in case proposer is illiterate)
Dated: ffi
10. Declaration in case the proooser is illiterate. and forn!.-is filled bv porEon other than proooser
hereby declare that I have explained the content of this form to the proposer in
(Language) which he/she easily unders{ands and that the proposer has affxed lhe thtmb impression
above after fully understanding the contents there of. I have carefully filled up the proposal form.
.#
Signature:
Dedararfs Name:
Ad*oas:
Date:
rk,
Certifed that I have caretully examined ShrilSmt. the proponenl whose
signature/thumb impression is given below today the-- Day of _
On careful examination of the proponent and after going through the information furnished by him/her under column I &9, I find the proponent
-.---20
to be medically fit. He/ She does not suffer from any terminal or other serious health hazard which would be risk to his/her life. I recommend
accaptance of his/her their proposal of Postal Life lnsurance policy.
OR
The proponent is medically unfit. I do not recommend acceptance of his/her proposal for Postal Life Insurance policy.
Name;
Seal:
Date: I lti I -!:r }',
tDlCode:
GST:
-
,::i.ri",,o: i-,:..:
RPII salesperson/Agents procuring RPLI poliry will carefi.rlly check & veri{' the following
do.crrments before completing the Confidential Report in respect of each RPIJ proposal:
-. 'i. Age proof (seH-attested/thumb impressed copy of any of the following documents
:r L StandardAge proof (anyof the following documents)
a. Birth Certifleate
b. School Certificate/Mark sheet
c. PAN Card
d. Passport
e. Driving License
II. Non-StandardAgePnoof(arryofthefollowingdocuments)
a. AadharCard
b. Eider's declaration
c. Medical Examiner's approximate age certificate
d. Declaration by insurant eounter signed by Panchayat l4ember
(This will consist of information not revealed in the proposal form. This will be completed by RPLI
Agent procuring poliry after proposal form is completed by proposer. Content of the record should
not be discussed with the proposer or divulged to him.)
Mobile No
Notes/Instructions for fiIling up the Froposal Forrn(Not to be scanned & uploaded)
1. Please provide valid proof of your age. In case youare not having any valid proof of d.ate of birth
you may produce any of the following documents (non standard age proof)* :
d. AadharCard
(*policy(ies) taken on non standard age proof will be charged S% additional premium)
2. Please mention your mobile number, email.IDat appropriate plaee. Mentioning mobile number
and email address will help us in sending SMS and e-mail alerts to you forvarious services of .
3. Nomination in Poliey will help in timely and hassle-fiee settlement of claim, if a policy becomes
a claim before date of maturity. Therefore, it is advisable to give nominee (s) details in eaeh
case.
4. In case poliry is taken under Married Women PropertyAct 1874, nomination in such case is not
required. In such case name of the beneficiary (i.e. wife) should be mentioned at serl 4 @ of
proposal form
Mentioning Aadhar/ PAN is optional. However, it would faeilitate us to provide better after salm
.services.
In case of change of address/nomination, proponent is advised to notifr the same to nearest
CPC concerned.
In case, nominee is minor, partieulars of person as appointee should be given at appropriate
place.
Please mentionyour BankAccount No. or Post OfHce Account, if any.
9. Willful concealment of anymaterial informationwill renderthe contractvoidable at anytime.
ro. Change of commtnication address, mqhile number or email address may be hrought to
information of Department to avail better after sales service.
rr. In case the proposer is illiterate the thumb impression of the pnoposer should be attested by a
percon of stand.ing whose identity can easily be established but unconnected with the Deptt. and.
this declaration should be made by him"