MCA Application Form — Bima Sakhi Scheme

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Header

Photo ready Cropped to 35 × 45 mm passport ratio

1. Personal

2. Address & Contact

3. Father / Husband

4. Birth / Health

5. Educational Qualification

InstitutionYear of Passing
S.S.C. or Equivalent
HSC (10+2) or equivalent
Graduation
Other

6. Languages

7. Occupation & Employment

Name of EmployerNature of WorkFromToScale of pay / last salaryReason & Date of leaving

8. Related to LIC personnel?

9. Relative working as Agent?

10. Past LIC History

11. Other Details

12. References (Two respectable persons)

13. Documents enclosed

Date & Signature

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Preview — A4, 3 pages
ANNEXURE – I
Affix
Passport
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photograph
LIFE INSURANCE CORPORATION OF INDIA
Branch, Division,Zone
APPLICATION FOR RECRUITMENT AS MAHILA CAREER AGENT UNDER
THE “MAHILA CAREER AGENT-LIC’s BIMA SAKHI SCHEME”
(To be filled in by the Applicant. Applicant is advised to read the “Instructions” before completing this Form)
1.
a)
Full Name (Block Letters with Surname First) :
b)
Nationality :
c)
Belong to (SC/ST/OBC/EWS/General) :
d)
Marital Status :
e)
Number of Children :
f)
Other Dependents :
2.
a)
Present Postal Address in full :
(Any changes in address should be
Communicated immediately.)Pin
b)
Permanent Address :
Pin
c)
Contact Number / Mobile Number :
d)
Email ID :
3.
Father’s / Husband’s Name :
Father’s / Husband’s Occupation :
Father’s / Husband’s Residential Address :
4.
a)
Date of Birth :
b)
Place of Birth (Town, District and State) :
c)
Usual state of health :
d)
Have any bodily defects or Deformity :
If so, give details
5.
Education Qualification :
Academic Record:
 InstitutionYear of Passing
S.S.C. or Equivalent  
HSC (10+2) or equivalent  
Graduation  
Other  
6.
Language you can-
a)
Read and Write :
b)
Speak :
Mother tongue :
7.
a)
Your Present occupation :
b) Particulars of Employment:
Name of Employer Nature of Work PERIOD Scale of pay and last Salary drawn Reason for leaving & Date of leaving
FromTo
      
      
c)
If self-employed, mention the nature of Occupation:
Annual Income :
d)
Have you ever been Adjudicated insolvent or :
applied for Insolvency
8.
Are you related to any Development officer / Employee / Medical Examiner of LIC of India ?
If YES, mention –
a)
His/Her Name & office where he /she works:
b)
Place :
c)
Designation :
d)
Relationship :
9.
Is there any relative, near or distant, who is working-
As an Agent?
If YES, give Agency Code Number, Branch
Office to which he is attached and exact relationship
10.
a)
Have you ever worked with LIC of India in the past, for any post?
 
If YES, give full details :
b) Have you at any time worked as an Agent with LIC, any General Insurance Company or any
Private Insurance Company ?
If YES, give full details
11.
Other Details :
a)
Are you having any debts?
If YES, Give full details
b)
Are you under an obligation to repay
money advanced by any person or Institution
for your education or for any other purpose ?
If YES, Give full details
c)
Have you ever been involved in any Criminal offence
and / or convicted by a court of Law?
If YES, Give full details
d)
Is any case pending against you in any Court of Law?
If YES, give full details
12.
Give Name and Address of two Respectable(i)
Persons who are well acquainted with you
but are not related to you and to whom,
if necessary, references can be made.(ii)
13.
Give list of the documents and attested certified copies of Certificates attached with this
application.
I hereby declare that I have read the instructions attached to this form and I declare that I accept all the terms and conditions as detailed therein. I also accept the condition that the decisions of the Corporation in all matters will be final and binding on me. I further declare that all information given by me in this application is true and to the best of my knowledge and belief and should it be otherwise, I shall be liable to such action as the Corporation may deem fit to take.
Dated at this day of 20
Total no. of enclosures
(Signature of Applicant)

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