1. No category

ern$q.ifrT{furfturd
Bfclnstmnci Corporotionof /ndio
Statementto srtbmittedby the proposer/ agent/ dev- Officerwhen a standardage proof
School/ university
/ Birthcertificateis not submittedalongwith the Proposat.
1.
Nameof Proponent
:
2.
Place and date of Birth :
3.
Proponent's
Educational
eualificationand
year of leavingSchoolor College:
I
4.
Proponent'soccupation:
5.
His employee's
Name& Address:
6.
Natureof age proof submitted:
7
Reasonfor not submitting
a standardproof of age :
( i ) ' l f p r o p o n e n t i s e d u c a t e d ,s t a t e w h y a
S c h o o l / U n i v e r s i t yC e r t i f i c a t ei s n o t
submitted.
(i i )
T h e r e a s o n s w h y b i r t h C e r t i f i c a t e ' i sn g t
submitted.
(i i i )
lf the proponentis in seruice,statewhy an
extract from service registercannot be
produced.
(iv)
lf the submittedage proof is eitheran eldeis
declarationof self-declarationstate reasons
for the same.
(v)
lf the submlttedage proof is a Horoscope,
slate reasonsfor the same.
I herebyagreethat the foregoingquestionand answersshall from part of the proposalfor
and theyshall
of Indiaon
insurancemadeby me.tobe Life InsuranceCorporatign
proposal
:
in
original
the
if
contained
as
be of the same effect
Dated al
Signatureof'theAgent
on the day
of -
200
Signatureof the ProPoser
'of
satisfied
I havediscussedthe questionirf standardproof age with the proposerandI am
:
that he/shecannot sunmitstandardpibot of the age for the followingreasons
I furthercertify that accordingto my estimationhis apparentage is :
year
Signatureo f t h e A g e t t t
proposerand I am sattsfrerj
I have discussedthe questionof standardproof of age with the
reasons:
that he/shecannotsubmitstandardproofof the age for the following