LIC — Application for Rural Career Agency

Fill the details below, then click Generate Form.

Header

1. Applicant

2. Address (Block Letters)

3. Father

4. Personal

5. Educational Qualification

6. Languages

7. Occupation

8. Relation to LIC personnel

9. References

10. Insurance history

11. Villages

12. Immovable property

Signature

Display Options

Preview — A4, 2 pages
ANNEXURE II
Division:
Branch:
APPLICATION FOR RURAL CAREER AGENCY
Note: - It is essential that complete details should be given in reply to the questions. Incorrect or insufficient information may result in the application being rejected.
1.(a) Name of the applicant (in full) (Mr. / Mrs. / Miss)
(In Block Letters, Surname first)
(b)Marital Status
(Single, Married, Widowed, Divorced)
:
 
:
 
2. Address (In Block Letters)
 
 
:
3. (a)Father's Name
(b) Father's Occupation
(c) Father's Residential Address
 
(d) Father's Annual Income (Approx.)
(a)
(b)
(c)
 
(d)
4. (a) What is your date of Birth
(b) What has been your usual
State of health?
 
(c) Have you any bodily defect or
Deformity, if so, give details
(a)
(b)
 
 
(c)
 
5. What is your educational Qualification?
:
6. Which language can you -
(a) Read and Write ?
 
(b) Speak only ?
 
(a)
 
(b)
7. (a) What is your present Occupation
(b) If in employment, state full
Name and address of Employer
nature of Employment.
(c) If self - occupied, State the nature
of occupation and Annual income.
(d) Have you ever been Adjudicated
insolvent or Applied for insolvency
(a)
(b)
 
 
(c)
 
(d)
 
8. Are you related to any of the Corporation's Development Officers, Employees of the Corporation, Medical Examiners or Agents? If so give Name, Designation and Territory of the office where he / she works and operates and also your relationship to him / her.
Name:
Designation:Territory:
Relationship:
9   Give name and address of two
responsible persons (not relatives
or employees of the Corporation) for
the purpose of reference.
(i)
 
(ii)
 
10. Do you now represent, or
have you at any time,
represented either directly or
indirectly this Corporation or
any general Insurance
Company or any Private
Insurance Company ?
:
 
 
 
 
11. Stat the Village's where you
intend to represent the
Corporation
:
 
 
12. Do you or your family own any immovable
property like agricultural lands, House, Etc.,
in the village/s mentioned in all above.
If so give details with approximate Annual
Income from these properties
 
 

I do hereby declare that the above mentioned statements and answers are to the best of my knowledge and belief, true and complete, that they shall be the basis of the contract of the agency between me and the Life Insurance Corporation of India and that if any of the above mentioned statements or answers are untrue or incomplete the said contract shall stand automatically terminated from the date on which such knowledge comes to the Corporation. I also agree that all decisions of the Corporation shall be binding on me and that I fully understand the meaning of Section 41 of the Insurance Act, 1938 produced below:-

Section 41:- “(1) No persons shall allow or offer to allow, either directly or indirectly as inducement to any persons to take out or renew or continue an insurance in respect of any kind of risk relating to lives property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with published prospectus or tables of the insurer.

(2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Five Hundred Rupees.”

I also agree to abide by this terms and conditions of the agency in force and advised to me from time to time and to conduct the agency, if granted, in a manner designed to promote the interest of the Corporation and its policyholders.

Signed at this day of 20
Signature of the Applicant
Specimen Signature of the Applicant