LIC Forms

3

Age Declaration by Parent

43

Specimen Signature Form

137A

Claim for Disability/Sickness Benefit under Nav Prabhat Plan

137B

Claim for Disability/Sickness Benefit under Nav Prabhat Plan

137C

Claim for Disability/Sickness Benefit under Nav Prabhat Plan

137D

Claim for Disability/Sickness Benefit under Nav Prabhat Plan

137E

Claim for Disability/Sickness Benefit under Nav Prabhat Plan

137F

Disability Claims Due To Accident And Sickness Under Nav Prabhat Plan

294

Addendum For Assurance On The Lives Of Minors & Non-earning Major Lives

295

Addendum to Proposal for family details

300

Proposal For Insurance on Own Life

311

Policy Lost Questionnaire

340

Proposal For Insurance On The Life Of Another Person

360

Proposal For Insurance On Another Person

440

Proposal Form For Jeevan Akshay VI

460

Health Declaration for New Policy

680

Health Declaration for Revival of Policies

700

Personal Statement Regarding Health

720

Health Declaration for Revival of Policies on Minor Life

827

Jeevan Rakshak Own Life

827A

Jeevan Rakshak Another Life

835

Proposal For New Endowment Plus Plan

904

Proposal Form For Health Insurance Policy

3166

Previous Policy Extract

3179

Consent For Extra

3237

Nomination form under Joint Life

3237A

Nomination form under Jeevan Saathi Policy

3251A

Special Moral Hazard - Annexure A

3251B

Special Moral Hazard - Annexure B

3260

Declaration By Proposer / Agent / D.O. for Standard Age Proof

3261

Stamped Age Declaration By Elder

3264

Nomination form

3265

Nomination form for Minor Nominee

3310

Report of Fluoroscopic Examination (Screening)

3311A

Report of Glucose Tolerance Test of Urine

3313

Report on X-ray (plain) of Genito Urinary Tract KUB Area

3314

Report on X-ray of Stomach & Duodenum (Barium meal)

3315

Report on X-ray of Caecum and Colon (Barium enema)

3316

Report on Intravenous – Pyelography

3317

Report of Cholecystography

3321

Sputum Examination

3322

Addendum for Asthama / Bronchitis

3324

Personal History of An Operation for Gastric or Duodenal Ulcer

3325

Personal History of Indigestion, Dypspepsia, Gastric or Duodenal Ulcer (not operated)

3326

Kidney / Colic / Stone History Questionnaire

3327

Personal History of Gall-bladder Disease

3330

Goitre (with operation)

3331

Goitre ( without Operation ) Questionnaire

3332

Filariasis Form

3333

Chest Pain Questionnaire

3334

C.N.S. Questionnaire

3335

Stool Report

3336

Tuberculosis Questionnaire

3337

Pleurisy Questionnaire

3340

Epilesy Questionnaire

3341

Gynaelogist Report

3344

SBT-27

3738

Appointment of Appointee

3740

Revocation of Appointment of Appointee

3741

Appointment of Fresh Appointee

3750

Change of Nomination

3757

Indemnity Bond For Duplicate Policy - In Multiple Case

3762

Stamped Declaration for Policy Loss - Duplicate Policy

3772

Declaration Of Health And Risk For Accident Benefit

3777

Queries To Be Answered By Army Personnel

3783A

Claimants Statement

3784B

Medical Attendants Certificate

3785

Burial Cremation Certificate

3787

Employers Certificate

3788

Confidential Report By The Agent

3801

Death Claim Discharge Form

3805

Claim

3805A

Claim Settlement

3805B

Form Of Letter Of Indemnity

3806

Form Of Application To Dispense With Legal Evidence Of Title

3806A

Form Of Application To Dispense With Legal Evidence Of Title

3815

Stamped Declaration for Policy Loss - Claim

3815A

Form Of Letter Of Indemnity

3815B

Judicial Form

3816B1

Certificate Of Hospital Treatment

3816B2

Certificate Of Treatment

3825

Maturity Value Discharge Form

3827

Certificate Of Existence

3828

Form Of Receipt To Be Furnished Under Educational Annuity

3848

Form of Assignment

4104A

Statement If Std. Age Proof Not Submitted

4104B

Age Extract

5074

Surrender Value Discharge Form

5096

Unstamped Self Age Declaration

5193A

Diving Questionnaire

5194

Successive, Alternative Nomination

5220

Stamped Self Age Declaration

5233

Form of Declaration for disability Benefit under a Policy

5279

Claim for Disability Benefit

5280

Claim for Disability Benefit

7554

Specimen Of Authorisation Letter

32851

Special M.H.R.

AD(C)-1

Cancer Claim under Asha Deep

AD(C)-2

Cancer (Malignant) Claim under Asha Deep

AD(CABG)-2

CABG Claim under Asha Deep

AD(CABG)-3

CABG Claim under Asha Deep

AD(KF)-1

Kidney Failure Claim under Asha Deep

AD(KF)-2

Kidney Failure Claim under Asha Deep

AD(KF)-3

Kidney Failure Claim under Asha Deep

AD(PS)-1

Paralytic Stroke Claim under Asha Deep

AD(PS)-2

Paralytic Stroke Claim under Asha Deep

Addendum1

Addendum to Proposal for Ceasarean History

Addendum2

Addendum For Multiple Proposals

Addendum3

Proposal Form For Jeevan Tarun

AD(CABG)-1

CABG Claim under Asha Deep

A-EC

Certificate Of Existence under Annuity

AIC

Certificate Of Agricultural Income

CA1

Chartered Accountants Certificate

Cat-I

Addendum to Proposal for Cat. I Female

Cat-III

Special MHR for Category III ladies

CIRB1

Claimants Statement For CIRB

CIRB2

Employers Certificate

CIRB3

Critical Illness (Heart Attack,CABG,HVR)

CIRB4

Claim Under Critical Illness Rider

CIRB5

Critical Illness (Cancer)

CIRB6

Claim Under Critical Illness Rider For Cancer

CIRB7

Critical Illness (Stroke)

CIRB8

Claim Under Critical Illness Rider For Stroke

CIRB9

Critical Illness (Kidney Failure)

CIRB11

Critical Illness (Aorta Graft Surgery)

CIRB12

Claim Under Critical Illness Rider For Aorta Graft Surgery

CIRB13

Critical Illness (Blindness)

CIRB14

Claim Under Critical Illness Rider For Blindness

CIRB15

Critical Illness (Third Degree Burns)

CIRB16

Claim Under Critical Illness Rider For Third Degree Burns

CIRB17

Critical Illness (Major Organ Transplant)

CIRB18

Claim Under Critical Illness Rider For Major Organ Transplant

CIRB19

Critical Illness (Paralysis)

CIRB20

Claim Under Critical Illness Rider For Paralysis

CIRB-C

Discharge Under Critical Illness Rider Benefit

DCPB

Day Care Procedure Benefit

Declaration1

Declaration For Splitting Of Large Sum Assured

Direct1

Premium Collection Facility Through LIC Nomura Mutual Fund

ECS1

IPP ECS Mandate Form

ECS4

ECS Mandate Form

HI-ClaimIntimation

Health Insurance Claim Intimation Form

HIDGH1

Personal Statement Regarding Health Plus Policies

HIDGH2

Personal Statement Regarding Health For Major Insured Member Under Health Plus Policies

HIDGH3

Personal Statement Regarding Health For Minor Insured Under Health Plus Policies

HOSPITAL CLAIM

Claim For HCB, MSB under Health Insurance Policy

HUF

HUF Addendum To Proposal

JA-1

Claim Under Survival Benefit Option II Of Jeevan Asha Plan

JA-2

Claim For Minor/Major Surgical Procedure Covered Under Jeevan Asha

JB(CDB)-1

Requirements Needed For Processing The Claim Under Critical Illness Rider

JB(CDB)-2

Claim Investigation Report Of Critical Illness Rider Benefit

JB(FCE)-3

Congenital Disability Benefit Claim Under Jeevan Bharati

JB(FCF)-2

Female Critical Illness Benefit Claim Under Jeevan Bharati

Juv FMR

JUVENILE FMR

KeyMan

KEYMAN QUESTIONNAIRE

KeyMan-A

Draft Of Resolution To Be Passed By Company Board For KeyMan Insurance

KeyMan-B

KEYMAN QUESTIONNAIRE

KeyMan-C

Income Declaration For Keyman Insurance

LI-Annuity

Form Of Letter Of Indemnity

LIC-03-002

ELECTROCARDIOGRAM

LIC-03-003

COMPUTERISED TREADMILL TEST

LIC-03-004

HAEMOGRAM

LIC-03-005

LIPIDOGRAM

LIC-03-006

BLOOD SUGAR TOLERANCE REPORT

LIC-03-007

SPECIAL BIO-CHEMICAL TESTS – 12 (SBT-12)

LIC-03-008

SPECIAL BIO-CHEMICAL TESTS – 18 (SBT-18)

LIC-03-009

ROUTINE URINE ANALYSIS

LIC-03-010

REPORT ON X-RAY OF CHEST (P.A. VIEW)

LIC-03-011

ELISA FOR HIV

LIC-03-012

PHYSICIAN’S REPORT

LIC-03-013

SPECIAL BIO-CHEMICAL TESTS – 13 (SBT-13)

LIC-03-500

GENERAL OCCUPATION QUESTIONNAIRE

LIC-03-501

ARMY PERSONNEL QUESTIONNAIRE

LIC-03-502

AVIATION (ARMED SERVICES) QUESTIONNAIRE

LIC-03-503

AVIATION (CIVIL) QUESTIONNAIRE

LIC-03-504

CIVIL GLIDING QUESTIONNAIRE

LIC-03-505

NAVY PERSONNEL QUESTIONNAIRE

LIC-03-506

DIVING (ARMED SERVICES AND COMMERCIAL) QUESTIONNAIRE

LIC-03-507

MERCHANT MARINE QUESTIONNAIRE

LICCard

Application form for Credit Card

MHR-III

Special MHR for Category III ladies

MI

DEATH CLAIM FORM UNDER MICRO INSURANCE POLICY

MSB

Annexure For Major Surgical Benefit

NB-56

MHR For Physically Handicapped Life

NB59

DEFORMITY QUESTIONNAIRE

NRI1

Moral Hazard Report For Mail Order Business

NRI2

SPECIAL QUESTIONNAIRE TO BE COMPLETED IN RESPECT OF NRIs

NRI3

QUESTIONNAIRE TO BE COMPLETED BY NON-RESIDENT INDIAN

PN74

ADDENDUM TO PROPOSAL FOR ASSURANCE ON THE LIVES OF MINORS AND NON-EARNING MAJOR LIVES

PPL1

Health Plus Plan Proposal Form – Addendum for Bank Details

Q-AA

Arthritis Questionnaire

Q-BP

High Blodd Pressure Questionnaire

Q-DA

Diabetes Questionnaire - Applicant

Q-DP

Diabetes Questionnaire - Physician

Q-EE

EMPLOYER – EMPLOYEE SCHEME QUESTIONNAIRE

Q-H

HERNIA QUERY FORM

Q-HA

High Blood Pressure Questionnaire – Applicant

Q-Hearing

Hearing Questionnaire

Q-HP

Hypertension Questionnaire – Physician

Q-MD

Musculoskeletal Disorders Questionnaire – Attending Physician

Q-Op

Ophthalmic Report

Q-PF

Personal Financial Questionnaire

Q-PL

Policy Lost Questionnaire

Q-RT

Residence and Travel Questionnaire

Reassign

Reassignment For Valuable Consideration

Recheck

Re-Check Of Measurements

Rev-0814

Hospital Treatment Form

Sup-deed

Specimen of Supplementary Deed Of Partnership