Proposal Form

Plan Details

Plan Name Plan No

LIC’s Index Plus 873

UIN
512L354V01
Agency Code Supervisor Code Branch Code
05418281 9999999 281

Access Id Email Id Mobile No.

2550584527 sainitanya1809@[Link] 9369318717
* Date of Proposal - Pertains to date when customer verified the proposal. Proposal number is
allotted only after receipt of the full proposal-deposit amount by LIC

Details of plan proposed

Term & PPT Sum Assured Installment Premium GST

15 - 15 ₹ 3,00,000 ₹ 2,500 ₹ 0
Total Amount Mode of Payment Date of
Commencement **
₹ 2,500 Monthly
14-06-2025
AB/ADDB Req AB/ADDB Sum Assured
AB REQUIRED ₹ 3,00,000
Sum Assured Option Fund Option
10 times of Flexi Smart
Annualized Growth Fund
Premium
Applicable to Police Personnel if LIC’s Accident Benefit Rider / LIC’s Accidental Death And Disability
Benefit Rider is opted for :
(i). Whether you are engaged in police duty in any police organization other than Yes No
paramilitary force?
If “Yes”, (ii). Whether you wish to avail the AB/AD& DB rider while on police duty? Yes No

** Date of Commencement - This date is tentative Date of Commencement , subject to change

based on date of payment and underwriting.
 BROAD INVESTMENT PATTERN OF THE INVESTIBLE FUNDS

Fund Investment Short-term Investment Details Risk SFIN No.

Type in investments in Listed and Profile
Government/ such as Equity objective
Government money Shares of the fund
Guaranteed market for risk
Securities/ instruments /return
Corporate
Debt
Flexi 0% to 20% 0% to 40% 40% to To provide Very ULIF00510
Growth 100% long term High /11/23
Fund capital risk LICULIPFL
appreciation X512
through
investment
primarily in
select
stocks
which are a
part of NSE
NIFTY100
Index
Flexi 0% to 20% 0% to 40% 40% to To provide Very ULIF00610
Smart 100% long term High /11/23
Growth capital risk LICULIPFS
Fund appreciation G512
through
investment
primarily in
select
stocks
which are a
part of NSE
NIFTY50
Index

Personal details of the life to be insured

Name
Tanya Saini
Father's Name Mother's Name
NARESH CHANDRA SHASHI SAINI
Gender
Male Female Third Gender

Martial Status Date of birth ABHA number

Single 18-09-2002
Age (in years) Residential Status
23 Years Resident Indian

Communication details of the life to be insured

Present Address for communication

Address Line 1 Address Line 2
C/O: Naresh Chandra, 35A, Ahirwan, sadanand nagar, , Kanpur, Kanpur
Nagar,
Address Line 3 City District
Uttar Pradesh sadanand nagar Kanpur Nagar
State Country Pin Code
Uttar Pradesh India 208007
Permanent Residential Address
Address Line 1 Address Line 2
C/O: Naresh Chandra, 35A, Ahirwan, sadanand nagar, , Kanpur, Kanpur
Nagar,
Address Line 3 City District
Uttar Pradesh sadanand nagar Kanpur Nagar

State Country Pin Code

Uttar Pradesh India 208007

KYC Particulars

Are you an It Assessee Yes No

PAN Proof of Identity Address Proof

PIBPS8478G ekyc ekyc

If Registered under GST Yes No

Occupation Details

Present Occupation Exact Nature of Name of the present Length of service

duties employer
Service (Listed Service 1 Years
Companies/Institutions)
Annual income source of income Education Purpose of
Qualification insurance
₹ 3,50,000 Employed Post Graduate
(Salary) or Graduate

Other Personal Details of the life to be insured

Is the life to be assured’s occupation associated with any specific hazard or does the life Yes No
to be assured take part in hazardous activities or have hobbies that could be dangerous
in any way? If yes , give details and submit respective questionnaire
Are you a Politically Exposed Person OR are you a family member or close relative of Yes No
Politically Exposed Person?[As per RBI guidelines PEPs are the individuals who are or
have been entrusted with prominent public functions bya foreign country].
Have you ever been or are currently being investigated, charge sheeted, prosecuted or Yes No
convicted or having pending charges in respect of any criminal/civil offences in any court
of law in India or abroad ?

Lifestyle Details of the Life to be Insured

Do you smoke / Yes/No If YES, Quantity If STOPPED, Since
consume or have you consumed and how may months
ever smoked / Duration
consumed the
following

Alcoholic drinks Yes No

Narcotics Yes No

Any other drugs Yes No

Do you smoke/consume Yes No

or have you
smoked/consumed
tobacco in any form (
cigars, cigarettes,
beedis, pan masala etc)
in the past 60 months.
(in sticks /packets/
sachets/gms per day)

Details of previous policies held / proposals applied of the life to be

insured

a) Is the life to be assured now being proposed for another assurance or an application Yes No
for revival of a policy or any other proposal under consideration in any office of the
Corporation or to any other Insurer? If yes, give Proposal no. / Policy no. and Branch Code
b) Whether proposed simultaneously on the life of spouse/ children/ parents ? If yes, give Yes No
Proposal no. and Branch Code
Has a proposal ( or an application for revival of a policy) on your life made to any office of the
Corporation or to any other Insurer ever been Accepted with extra or modified terms, Withdrawn,
Deferred, Dropped or Declined?, if yes give proposal number& branch / policy number / Name of
Insurer Yes No

Have you / Life to be assured during the past one year returned any policy of the Corporation as
the same was not acceptable ?, if yes give give policy number. Yes No

I hereby declare that I do not have any existing policies in-force or lapsed policies with LIC.

I hereby declare that I do not have any existing policies in force or lapsed policies with other Insurers.

Medical details of the life to be insured

Are you suffering from or have you ever suffered or undergone investigation in the past or have
you been advised to undergo investigation or treatment for the following ailments
1. Lungs/ Respiratory Disease / Persistent cough, asthma, bronchitis, pneumonia, Yes No
Tuberculosis/, pleurisy / spitting of blood/Covid 19etc
2. Peptic ulcer/colitis, jaundice,Hepatitis, anaemia, piles, dysentery, or any other disease Yes No
of the stomach, liver, spleen, gall bladder or pancreas/ digestive disorder
[Link], Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, Yes No
any disease of the heart or arteries?

Yes No
 4. Endocrine disorders such as Diabetes, Goitre, Thyroid etc or have you ever passed Yes No
sugar, albumin, pus or blood in urine
5. Any disease of kidney /prostate or urinary system? Yes No

6. Bone / Joint/ Spine Disease/ Arthritis / varicose veins /any bodily defect or deformity Yes No

7. Any disease of ear, nose, throat or eyes, including defective sight or hearing and Yes No
discharge from the ears
8. Cancer/leukemia/lymphoma/ tumour / cyst/ Any other growth / lumps/ blood disorder Yes No
/enlarged glands
[Link]/epilepsy/ insanity/ tremors, numbness, double vision, dizzy or fainting spells/ Yes No
head Injury / insomnia/ nervous breakdown / Mental Disorder (Depression/ Anxiety, etc.).
/ any other disease of the brain or the nervous system
10. Chronic infections- Skin Disease/ skin eruption/ Leprosy / ,filariasis, gonorrhoea, Yes No
syphilis or any other venereal disease or AIDS&HIV related condition
11. Hernia/hydrocele, varicocele, fistula Yes No

12. Any other disease ? Yes No

Medical History of the life to be insured

Please state exact height and weight ( without shoes)

Height (in cms) Weight (in Kgs)
155 52
During the last five years did you consult a Medical Practitioner for any Yes No
ailment requiring treatment for more than a week ?
Have you ever been admitted to any hospital or nursing home for general Yes No
check up, observation, treatment or operation?
Have you remained absent from place of work on grounds of health during the Yes No
last 5 years ?

Family History

(Please mention specifically if suffering from or died of heart disease, stroke, high blood pressure,
diabetes mellitus, cancer, kidney disease or any hereditary disorders, Insanity, or any contagious
diseases such as tuberculosis ,hepatitis, AIDS / HIV etc)

Relationship Living/Dead Present age State of Age of Death Cause of

Health Death

Father Living 49 Good NA NA

Mother Living 45 Good NA NA

Brother Living 4 Good NA NA

Female Life (if applicable)

Are you pregnant now? Yes No

Have you had any delivery history? Yes No

Yes No
 Have you had any abortion or miscarriage or Cesarean section? Yes No

Have you ever consulted a gynecologist or undergone any investigation, treatment for Yes No
any gynaec ailment?

Bank details of the life to be insured

Your bank account type Savings Current

Account Number IFSC Code Bank Name

8858010000038146 DBSS0IN0858 DBS BANK INDIA LIMITED

Settlement Option of Life to be Insured

Do you Wish to avail Option for Death Benefit in installments Yes No

Nomination Details

Particulars of Nomination

SI No. name of Age Relationship Address of

the to the life Nominee Share(%)
Nominee assured
1 SHASHI 45 Mother C/O: Naresh 100
SAINI Chandra, 35A,
Ahirwan,,sadanand
nagar, , Kanpur,
Kanpur
Nagar,,sadanand
nagar,sadanand
nagar, 208007

Mobile Email Bank Name Account No

Number IFSC
Code

Summary of Section 45 of Insurance Laws (Amendment) Act 2015

(1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three
years from the date of the policy, i.e., from the date of issuance of the policy or the date of commencement of
risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
(2) A policy of life insurance may be called in question at any time within three years from the date of issuance
of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to
the policy, whichever is later, on the ground of fraud : Provided that the insurer shall have to communicate in
writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and the
materials on which such decision is based.
Explanation I
For the purpose of this sub section, the expression "fraud" means any of the following acts committed by the
insured or by his agent, with the intent to deceive the insurer or to induce the insurer to issue a life insurance
policy :
(a) The suggestion, as a fact of that which is not true and which the insured does not believe to be true.
(b) The active concealment of a fact by the insured having knowledge or belief of the fact.
(c) Any other act fitted to deceive.
(d) Any such act or omission as the law specially declares to be fraudulent.
Explanation II
Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless the
circumstances of the case are such that regard being had to them, it is the duty of the insured or his agent,
keeping silence to speak, or unless his silence is, in itself, equivalent to speak
Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the
ground of fraud if the insured can prove that the mis-statement of or suppression of a material fact was true to
the best of his knowledge and belief or that there was no deliberate intension to suppress the fact or that such
mis​statement of or suppression of a material fact are within the knowledge of the insurer: Provided that in case
of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
Explanation:
A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the formation
of the contract, to be agent of the insurer.

(4) A policy of life insurance may be called in question at any time within three years from the date of issuance
of the policy or the sommencement of risk or the date of revival of the policy or the date of the rider to the
policy, whichever is later, on the ground that any statement of or suppression of a fact material to the
expectancy of the life of the insured was incorrectly made in the proposal or other document on the basis of
which the policy was issued or revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or
nominees or assignees of the insured the grounds and materials on which such decision to repudiate the policy
of life insurance is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a
material fact, and not on ground of fraud, the premiums collected on the policy till the date of repudiation shall
be paid to the insured or the legal representatives or nominees or assignees of the insured within a period of
ninety days from the date of such repudiation.
Explanation:
For the purposes of this sub-section, the mis-statement of or suppression of fact shall not be considered
material unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show
that had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to
do so, and no policy shall be deemed to be called in question merely because the terms of the policy are
adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.

Summary of Section 41 of Insurance Laws (Amendment) Act 2015

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out
or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate
of the whole or part of the commission payable or any other 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 the published prospectuses or tables of the insurer.
Signature of the life to be
Assured
 Declaration of the life to be insured

I Tanya Saini the person whose life is herein being proposed to be assured, do hereby declare that the
foregoing statements and answers have been given by me after fully understanding the questions and the
same are true and complete in every particular and that I have not withheld any information and I do hereby
agree and declare that these statements and this declaration shall be the basis of the contract of assurance
between me and the Life Insurance Corporation of India . And I further agree that if after the date of submission
of the proposal but before the issue of First Premium Receipt (i) any change in my occupation or any adverse
circumstances connected with my financial position or the general health of myself or that of any members of
my family occurs or (ii) if a proposal for assurance or an application for revival of a policy on my life made to
any office of the Corporation is withdrawn or dropped, deferred or accepted at an increased premium or subject
to a lien or on terms other than as proposed, I shall forthwith intimate the same to the Corporation in writing to
reconsider the terms of acceptance of assurance. Any omission on my part to do so shall render this contract to
be dealt with as per provisions of Section 45 of the Insurance Act, 1938, and that if any untrue averment be
contained therein the said contract shall be dealt with as per provisions of Section 45 of the Insurance Act,1938
as amended from time to time. Not-withstanding the provision of any law, usage, custom or convention for the
time being in force prohibiting any doctor, hospital, diagnostic center and/or employer, reinsurer/ credit bureau
from divulging any knowledge or information about me concerning my health or employment , occupation,
insurance , financials etc. on the grounds of privacy, I , my heirs, executors, administrators and assignees or
any other person or persons, having interest of any kind whatsoever in the policy contract issued to me, hereby
agree that such authority , having such knowledge or information, shall at any time be at liberty to divulge any
such knowledge or information to the Corporation, and the Corporation to divulge the same to any Authorised
Organisation / Institution / Agency / and Governmental / Regulatory Authority for the sole purpose of
underwriting / investigation / risk mitigation / fraud control and/or claim settlement. I am aware that if the
information on my Tax Residency is found to be false or untrue or misleading or misrepresenting, I may be held
liable for it. I also undertake to inform the Corporation of any change in my Tax Residency status. I undertake to
inform the Corporation immediately of any changes in KYC documents such as residence. I also give my
consent to obtain and share my data from / with Central KYC Registry and to receive phone calls , SMS/ E mail
from Central KYC registry in this regard. I understand that the Corporation reserves the right to accept
/Postpone/ drop/ decline or offer alternate terms on this proposal for life insurance . I hereby give my consent to
receive phone calls, SMS/whatsapp messages, E mail on the below mentioned registered number(s)/ E mail
address from / on behalf of the Corporation with respect to my life insurance policy/regarding servicing of
insurance policies/ notifying about the status of Claim I understand that if I have deposited “application money”
as a token consideration under this proposal for insurance, the closing NAV of the date of completion only will
be applied for allotment of units. I also understand that the premiums, charges and benefits under the policy
are subject to taxes / duties/ charges in accordance with the laws as applicable from time to time.
Signature of the Life
to be insured

Name Address Pin Code

Tanya Saini C/O: Naresh Chandra, 35A, Ahirwan, 208007
sadanand nagar, , Kanpur, Kanpur
Nagar, Kanpur Nagar Uttar Pradesh

Suitability Analysis

Proposer Full Name Date of Birth

Tanya Saini 18-09-2002
Age Maritial Status Occupation
23 Years Single Service (Listed Companies/Institutions)

Address
C/O: Naresh Chandra, 35A, Ahirwan, sadanand nagar, , Kanpur, Kanpur Nagar,
sadanand nagar 208007
2. What is proposer'yearly income from: (if life assured is different from the proposer)
Employment Businees / Profession Other Sources H.U.F. if any

Income of life to be
assured

3. Whether income proof submitted? (if Yes, give details below)

Nature of document Is he/she Income tax Is yes, please provide Income Tax Bracket
for income verification Assessee PAN
No PIBPS8478G
4. Previous Policy Details (as per proposal form)
5. Family History (as per proposal form)
Spouse Details
Name Occupation Annual Income
NA NA NA
6. Need Analysis
Total Annual Income
₹ 3,50,000
Outstanding Liablities
Secured Loans Non-Secured Loans

based on his age and income, the maximum insurance that can be granted is:
Age Group Multiple of Avg. Maximum allowable
Annual Income Insurance

7.
Object of Insurance How would you like to pay your premiums
Monthly

Risk Profile Time frame for this invesement

8. Categorization of plans in relation to object of Insurance

Category Risk Profile Plan Name
LIC’s Index Plus
9. Product Chosen
Plan No Plan Name Term Sum Assured
873 LIC’s Index Plus 15 ₹ 3,00,000
Mode Premium
Monthly ₹ 2,500

a) if ULIP is proposed:
1st Year 2nd Year 3rd Year onwards Life cover
charges

Policy Administration Fund Management

Charges Charges

b) if Annuity / Pension is proposed:

Target Annuity per annum Type of Annuity Annuity Amount per Defement
annum Period
Is the total insurance added to the present proposal is reasonable in relation to income
The questions above pertain to your personal condition at the time of appliction to your understanding of the
features of the product for which you are applying. This information will not be used for any other purpose and
will remain confidential.
I Tanya Saini, having received the informationwith respect to the above, have understood the selection of
product befor into this contract. My plan details are as following:
Plan No Plan Name Term Sum Assured
873 LIC’s Index Plus 15 ₹ 3,00,000
Mode Premium
Monthly ₹ 2,500

KYC Details of Life to be Insured as per E-KYC

Personal Details
Pan No
PIBPS8478G
Name Date of Birth
Tanya Saini 18-09-2002
Gender
Female

Contact Details
C/o. House/ Bldg. / Apt.

Steert/ Road/ Lane Landmark

C/O: Naresh Chandra, 35A, Ahirwan, sadanand nagar, , Kanpur, Kanpur
Nagar,

Area/ Locality/ Sector Pincode

208007

Village/ Town/ City P.O.

sadanand nagar
District State
Kanpur Nagar Uttar Pradesh
 LIC's Index Plus (Plan No. 873)

Benefit Illustration

LIC's Index Plus (Plan No. 873)

A Non-par, Linked, Life Individual Savings Plan
(Unique Identification Number - 512L354V01)

Distribution channel Offline Agency name SRI JAI PRAKASH OJHA Agency code 05418281
Name of prospect TANYA SAINI Age of prospect 22 years Date of illustration 14-06-2025
Name of life assured TANYA SAINI Age of life assured 23 years Benefit UID
Mode of payment of
Policy term 15 years Premium paying term 15 years Monthly
premium
Sum assured 3,00,000 Instalment premium 2,500.00 GST rate 18.00%
Investment strategy
Fund opted Flexi smart growth fund Risk level Very high risk Self managed
opted for
LIC's Linked ADB rider Opted AB rider sum assured 3,00,000
Death benefit option 2 Sum assured multiple 10

How to read and understand this benefit illustration?

This benefit illustration is intended to show what charges are deducted from your premiums and how the unit fund, net of charges and taxes, may grow over the years of the
policy term if the fund earns a gross return of 8% p.a. or 4% p.a. These rates, i.e., 8% p.a. and 4% p.a. are assumed only for the purpose of illustrating the flow of benefits if
the returns are at this level. It should not be interpreted that the returns under the plan are going to be either 8% p.a. or 4% p.a.

Net yield mentioned corresponds to the gross investment return of 8% p.a., net of all charges but does not consider mortality, morbidity charges, underwriting extra, if any,
guarantee charges and cost of riders, if deducted by cancellation of units. It demonstrates the impact of charges exclusive of taxes on the net yield. Please note that the
mortality charges per thousand sum assured in general, increases with age.

The actual returns can vary depending on the performance of the chosen fund, charges towards mortality, morbidity, underwriting extra, cost of riders, etc. The investment risk
in this policy is borne by the policyholder, hence, for more details on terms and conditions please read sales literature carefully.

Part A of this statement presents a summary view of year-by-year charges deducted under the policy, fund value, surrender value and the death benefit, at two assumed rate
of return. Part B of this statement presents a detailed break-up of the charges, and other values.

Page 1
 LIC's Index Plus (Plan No. 873)

Part A:

(Amount in rupees)

At 4% p.a. gross investment return At 8% p.a. gross investment return

Other Other
charges charges
(including (including
GST GST
Annualized FMC and FMC and
Policy year (excluding (excluding
premium GST on GST on
Mortality GST on Fund at end Surrender Death Mortality GST on Fund at end Surrender Death
FMC but FMC but
charges FMC and of year value benefit charges FMC and of year value benefit
excluding discontinua excluding discontinua
discontinua nce charge) discontinua nce charge)
nce charge nce charge
and its and its
GST)* GST)*
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)

1 30000 360 2750 518 26942 23402 300000 359 2754 518 27502 23962 300000

2 30000 325 2441 377 55458 53098 300000 323 2463 377 57696 55336 300000

3 30000 288 2899 371 84693 82923 300000 284 2958 370 89841 88071 300000

4 30000 251 3369 364 114664 113484 300000 242 3485 362 124062 122882 300000

5 30000 213 3851 357 145389 145389 300000 198 4047 354 160495 160495 300000

6 30000 176 4864 445 177159 177159 300000 152 5164 441 199539 199539 300000

7 30000 137 5423 447 208767 208767 300000 103 5852 440 240144 240144 300000

8 30000 98 5981 449 241109 241109 300000 50 6569 440 283311 283311 300000

9 30000 56 6554 451 274201 274201 300000 4 7330 441 329189 329189 329189

10 30000 17 7142 454 309855 309855 315000 0 8138 451 379694 379694 379694

11 30000 6 7773 463 344496 344496 346500 0 9025 462 431510 431510 431510

12 30000 1 8391 473 379886 379886 379886 0 9935 473 486517 486517 486517

13 30000 0 9024 485 416038 416038 416038 0 10902 485 544910 544910 544910

14 30000 0 9672 497 452963 452963 452963 0 11926 497 606900 606900 606900

15 30000 0 10336 510 496203 496203 496203 0 13014 510 678025 678025 678025

*See 'Part B' for details

Force Majeure Conditions:

a. The Corporation shall value the funds (SFIN) on each day for which financial markets are open. However, the Corporation may value the SFIN less frequently in extreme

Page 2
 LIC's Index Plus (Plan No. 873)

circumstances external to the Corporation, i.e. in force majeure events, where the value of the assets is too uncertain. In such circumstances, the Corporation may defer
the valuation of the assets for up to 30 days until the Corporation is certain that the valuation of SFIN can be resumed.
b. The Corporation will inform IRDAI of such deferment of the valuation of assets. During the continuance of the force majeure events, all requests for servicing the policy,
including policy related payment, shall be kept in abeyance.
c. The Corporation will continue to invest as per the investment pattern of the fund type opted by the policyholder. However, the Corporation reserves the right to change the
exposure of all or any part of the fund to money market instruments (as defined under Regulations 1(8) Schedule III of IRDAI(Actuarial, Finance and Investment functions of
Insurers) Regulations, 2024) in circumstances mentioned under points (a) and (b) above. The exposure of the chosen fund shall be reinstated within reasonable timelines
once the force majeure situation ends.
d. Few examples of such circumstances as mentioned in point (a) & (b) above are:
i. When one or more stock exchanges which provide a basis for valuation of the assets of the fund are closed otherwise than for ordinary holidays.
ii. When, as a result of political, economic, monetary or any circumstances which are not in the control of the Corporation, the disposal of the assets of the fund would be
detrimental to the interests of the continuing policyholders.
iii. In the event of natural calamities, strikes, war, civil unrest, riots and bandhs.
iv. In the event of any force majeure or disaster that affects the normal functioning of the Corporation.
e. In such an event, an intimation of such force majeure event shall be uploaded on the Corporation’s website for information.

IN THIS POLICY, THE INVESTMENT RISK IS BORNE BY THE POLICYHOLDER AND THE ABOVE INTEREST RATES ARE ONLY FOR ILLUSTRATIVE PURPOSE.

I, ________________________________________ (name), have explained I, ________________________________________ (name), having received

the premiums, charges and benefits under the product fully to the the information with respect to the above, have understood the above statement
prospect/policyholder. before entering into the contract.
Place : Place :
Date : Signature of agent/intermediary/official of the insurer Date : Signature of prospect/policyholder

Page 3
 LIC's Index Plus (Plan No. 873)

Part B:

(Amount in rupees)

Gross yield (p.a.) 8.00% Net yield (p.a.) 5.78%

GST
Annualize (excluding
Premium d premium Accident FMC
GST on Policy Addition Fund (including Fund after Guarantee Refund of Fund at
Policy Annualize allocation less Mortality benefit Surrender Death
FMC and admin to the before d addition mortality end of
year d premium charge premium charge rider tax charge FMC value benefit
discontinu charge fund FMC charge year
(PAC) allocation charge on FMC)
ance
charge charge)
(12)=(10)-
(1) (2) (3) (4)=(2)-(3) (5) (6) (7) (8) (9) (10) (11) (13) (14) (15) (16) (17)
(11)
1 30000 2400 27600 359 518 0 120 1133 27736 234 27502 0 0 27502 23962 300000

2 30000 1650 28350 323 377 0 120 3357 58389 693 57696 0 0 57696 55336 300000

3 30000 1650 28350 284 370 0 120 5757 91029 1188 89841 0 0 89841 88071 300000

4 30000 1650 28350 242 362 0 120 8312 125778 1715 124062 0 0 124062 122882 300000

5 30000 1650 28350 198 354 0 120 11031 162772 2277 160495 0 0 160495 160495 300000

6 30000 1200 28800 152 441 975 120 13901 201508 2869 198639 900 0 199539 199539 300000

7 30000 1200 28800 103 440 1024 120 17001 243653 3509 240144 0 0 240144 240144 300000

8 30000 1200 28800 50 440 1075 120 20226 287485 4174 283311 0 0 283311 283311 300000

9 30000 1200 28800 4 441 1129 120 23654 334070 4882 329189 0 0 329189 329189 329189

10 30000 1200 28800 0 451 1185 120 27295 383527 5633 377894 1800 0 379694 379694 379694

11 30000 1200 28800 0 462 1244 120 31303 437971 6460 431510 0 0 431510 431510 431510

12 30000 1200 28800 0 473 1307 120 35414 493825 7309 486517 0 0 486517 486517 486517

13 30000 1200 28800 0 485 1372 120 39779 553120 8210 544910 0 0 544910 544910 544910

14 30000 1200 28800 0 497 1440 120 44413 616066 9166 606900 0 0 606900 606900 606900

15 30000 1200 28800 0 510 1513 120 49332 682890 10181 672708 3600 1716 678025 678025 678025

Page 4
 LIC's Index Plus (Plan No. 873)

(Amount in rupees)

Gross yield (p.a.) 4.00%

GST
Annualize (excluding
Premium d premium Accident FMC
GST on Policy Addition Fund (including Fund after Guarantee Refund of Fund at
Policy Annualize allocation less Mortality benefit Surrender Death
FMC and admin to the before d addition mortality end of
year d premium charge premium charge rider tax charge FMC value benefit
discontinu charge fund FMC charge year
(PAC) allocation charge on FMC)
ance
charge charge)
(12)=(10)-
(1) (2) (3) (4)=(2)-(3) (5) (6) (7) (8) (9) (10) (11) (13) (14) (15) (16) (17)
(11)
1 30000 2400 27600 360 518 0 120 570 27172 230 26942 0 0 26942 23402 300000

2 30000 1650 28350 325 377 0 120 1660 56129 671 55458 0 0 55458 53098 300000

3 30000 1650 28350 288 371 0 120 2793 85822 1129 84693 0 0 84693 82923 300000

4 30000 1650 28350 251 364 0 120 3955 116263 1599 114664 0 0 114664 113484 300000

5 30000 1650 28350 213 357 0 120 5146 147470 2081 145389 0 0 145389 145389 300000

6 30000 1200 28800 176 445 975 120 6354 178828 2569 176259 900 0 177159 177159 300000

7 30000 1200 28800 137 447 1024 120 7615 211846 3079 208767 0 0 208767 208767 300000

8 30000 1200 28800 98 449 1075 120 8870 244695 3586 241109 0 0 241109 241109 300000

9 30000 1200 28800 56 451 1129 120 10154 278307 4105 274201 0 0 274201 274201 300000

10 30000 1200 28800 17 454 1185 120 11467 312692 4637 308055 1800 0 309855 309855 315000

11 30000 1200 28800 6 463 1244 120 12882 349704 5209 344496 0 0 344496 344496 346500

12 30000 1200 28800 1 473 1307 120 14256 385651 5764 379886 0 0 379886 379886 379886

13 30000 1200 28800 0 485 1372 120 15660 422370 6332 416038 0 0 416038 416038 416038

14 30000 1200 28800 0 497 1440 120 17094 459874 6911 452963 0 0 452963 452963 452963

15 30000 1200 28800 0 510 1513 120 18558 498178 7504 490675 3600 1929 496203 496203 496203

Notes:

1. Refer the sales literature for explanation of terms used in this illustration.
2. Fund management charge is based on the specific fund option(s) chosen.
3. In case rider charges are collected explicitly through collection of rider premium, and not by way of cancellation of units, then such charges are not considered in this
illustration. In other cases, rider charges are included in other charges.
4. The above illustrations are for indicative purpose. The annual charges shown above are sum total of charges deducted throughout the policy year as per the
frequency/conditions detailed in sales brochure/policy document.
5. This illustration is prepared by considering standard life (from medical, life style and occupation point of view).

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 LIC's Index Plus (Plan No. 873)

6. In case LIC's Accidental Death Benefit rider is opted for, rider charges are included in other charges under part A. However, under part B, accident benefit rider charge is
shown separately.
7. Fund at the start shall be the amount available for investment in the first year and previous year's end fund for rest of the years.
8. Above calculations have been performed considering deductions of mortality charge, policy administration charges and tax charge on these charges at the start of each
policy month and deduction of FMC and Tax charge on FMC the end of each policy month.
9. Tax charge (currently GST) is subject to change from time to time.
10. Total death benefit is the amount payable immediately on death of the life assured, which is higher of (basic sum assured reduced by partial withdrawal made during the
two years period immediately preceding the date of death) or unit fund value or (105% of the total premiums received reduced by partial withdrawal during the two years
period immediately preceding the date of death), where basic sum assured is (7 times of annualized premium), for age greater than 50 years and (7 or 10 times of
annualized premium as per the choice), for age less than or equal to 50 years.
11. The death benefit has been calculated assuming that death occurs on completion of the policy year and the option of partial withdrawal has not been exercised.
12. In addition to death benefit, accident benefit sum assured is payable as per terms and conditions of the policy, if LIC's Accidental Death Benefit rider is opted for and
death occurs due to accident.
13. The above illustration assumes the policy is surrendered on completion of the policy year after addition of guaranteed addition in unit fund. In case the policy is
surrendered on or before 5 years' lock-in-period, surrender value shown above equals unit fund value at the end of policy year minus discontinuance charge minus tax
charge on discontinuance charge. This amount shall be transferred to the discontinued policy fund and the proceeds of the discontinued policy fund shall be payable on
completion of 5 years' lock-in-period. In case the policy is surrendered after expiry of 5 years' lock-in-period, the surrender value shall be payable immediately.
14. For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale.

I, ________________________________________ (name), have explained I, ________________________________________ (name), having received

the premiums, charges and benefits under the product fully to the the information with respect to the above, have understood the above statement
prospect/policyholder. before entering into the contract.
Place : Place :
Date : Signature of agent/intermediary/official of the insurer Date : Signature of prospect/policyholder

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