tj

ll
;J
C0l-3820 wnnnNGAL loN
(Estabtishect by the Lite insuranee $oiporation of; ffffF
f,H&HGE 's4
LIFE INSUMNCE CORPOMNON OF IflDIA LIC'S JEEVAN SARAL (wrrH - pRoFrrs)
THE LIFE INSURANCE CORPORATION OF INDIA (hereinafter called "The Corporation") having received a Proposal and Declaration,
and the first premium from the Proposer and the Life Assured named in the schedule referred to herein below and the said Proposal I
and declaration with the statements contained and referred to therein having been agreed to by the said Proposer and the Corporation
as basis of this assurance do by this Policy agree, in consideration of and subject to the due receipt of the subsequent premiums as
set out in the Schedule, to pay the Sum Assured, but without interest at the Branch Office of the Corporation where this Policy is
serviced, to the person or persons to whom the same is payable in terms of the said Schedule, on proof to the satisfaction of the
Corporation of the Sum Assured having become payable as set out in the Schedule, of the title of the said person or persons claiming
payment and of the correctness of the age of the Life Assured stated in the Proposal if not previously admitted.
And it is hereby declared that the Policy of Assurance shall be subject to the conditions and privileges printed on the back hereof and
that the following schedule and every endorsement placed on the Policy by the Corporation shall be deemed part of the Policy.
SCHEDULE
DlvlsloNAl orrlEeflryffiffiffiAt- {136S} Branchtffile:
1. Policy No. Maturity Sum Assured (Rs.) Instalment Premium for main Plan (Rs.)
2. Date of Commencement Death benefit Sum Assured under main plan (Rs,) lnstalment Accident Benefit Premium (Rs.)
3. Date of Commencement Risk Accident Benefit Sum Assured (Bs.) lnstalment Term Rider Premium (Rs.)
4. Table & Term Term Rider Sum Assured (Rs.) Total lnstatment Premium (Rs.)

*s8*.t ?{}s4 E
3TJ SS{* JI ?iiit. {t{t
3Etl,:r{!(1 ?Eii!. (tt?
13/{}3'lf,:} 3 * J:. I SBtlt++ti , tltl
: ?ill "Il, t}{}
Nominee under Seclion 39 of the lnsurance Act,193B
Due Date ofpremium ESth
S SfifuAf,41{JS,t*I {*ifa Mode of Pavment of t"tY
Name and Address of the Proposer and Life Assured
premium 15/O3/Ar:3r]
Date o, Last Premium Payment
DIVX T I ruSN5I}IHAS}"JAI.'Y Dare of '
Maturirv 15,/(t3rr3{t3l
6/S SATHATAH, HNfr , ?*l l -5{rl./4 n (rt.I(tg./ 1??3
Date ol Birth
UI JAYANSGAR rOLS}.IY , VT DY$'fiA}I}'*PLF{: B?
Age of lhe Life Assured .,1
HAI}AFINSFIDA' ST TC&RHBJ{L
so&(l(,9 Whelher Age admitted
Proposar No f l? I ?
Date Ot Proposal
l=/(r3./Ettltl
Maturity Benefit ln the event of the Life Assured surviving the date of maturity a sum equal to Maturity Sum Assured in
force after partial surrenders, if any, along with the corresponding loyalty addition, il any, shall be payable.

Benefit on death A sum equal to the Death Benefit Sum Assured along with all premiums paid (excluding premiums paid for
the first policy year, any extra premium and premiums in respect ol Bider Benefits) shall be payable
provided the policy is in f ull force on the date ol death. Loyalty addition, il any, shall also be payable. lf the
proposer and /or Life Assured had surrendered the policy partially, as per terms oJ this policy, the benefit
shall be reduced in proportion oJ the reduction in premium lor the main plan.

To whom Sum Assured payable The proposer or his Assignees or Nominees under section 39 of the lnsurance Act 1 938 or proving Executors
or Administrators or other Legal Representatives who should take out representations to his Estate or Limited
to the moneys payable under this policy from any Courl of any State or Territory of the Union of lndia.

Period during which premium payable Till the stipulated date of Last Payment or previous death of the Life Assured.

Dates when premium payable on the stipulated due date n nl{nrcrt

SPECIAL PBOVISIONS:
1. Term Rider Benefit : lf option is exercised and Term Rider premium is paid, an additional amount equal lo the Term Rider Sum assured
as shown inthe Schedule will be payable on death before the date of maturity provided the policy is in full force.
2. Accident Benefit Rider : Para 1 1 of Conditions & Privileges ol this policy given overleaf , will be applicable if Accident Benefit is opted for

and Accident Benefit Premium is paid. lf option is nol exercised, Para 1 1of Conditions and Privileges of this policy shall not apply.
3. The non{orfeiture regulations & Participation in profits as contained in Conditions and privileges will not apply to Term Rider Benefit and
accident Benefit.
4. ln case of partial Surrenders, para-8 of Conditions and Privileges of this policy shall apply.

Signed on behalf of the Corporation at the above mentioned Branch Office whose address is given below and to which all communications
relating to the policy should be addressed :

BRANGH oFFlcE ADDRESS

Dare: z7 t4AR: Itc
FLtr&EI 5fl8
Examined by: LAS"T F&frT
rabreNo.165
[AJ*