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Form 14 - Application For Financing A Life Insurance Policy Out Of The Provident Fund Account Page 2

(i)

The authorisation at Para I(ii) above shall be effective only when

my life, insurance policy duly assigned to the Central Board of

Trustees, Employees’ Provident Fund has been received by the

Commissioner after proper registration of the assignment in the

books of the said Corporation.

(ii)

The said authorisation shall thereafter remain operative till such

time as I continue to be a member of the fund and have enough

accumulations to my credit as my own share in the fund, or till the

maturity of the policy, whichever is earlier.

(iii)

The terms of the policy shall not be altered nor shall the policy be

exchanged for another policy without the prior written consent of

the Regional Commissioner.

The policy is enclosed for inspection/will be forwarded when received/has

already been assigned to the Central Board of Trustees of the Employees’

Provident Fund and accepted by the Commissioner vide his letter

No……….. dated the ………………

I am aware that the policy is to be assigned to the Central Board of

Trustees of the Employees’ Provident Fund as Security within six month is

of the date of the first remittance by the fund to the said Corporation and

sent to the Commissioner after registration of the assignment in the books

of the said Corporation.

I declare that –

(a)

I have been a member of the fund for the period of not less than

two years which is the minimum period for being eligible for

financing the insurance policy from the fund.

(b)

The amount standing to my credit in my E.P.F Account (my own

share) is Rs……………….. as on ………………….. which is

sufficient for making payment to LIC for two years.

(c)

My annual contribution to the fund is Rs. …………… which is

sufficient to pay my yearly premia.

(d)

I propose to nominate the same person as for the P.F.

I also declare that the policy is free from any encumbrances and the

details of the *policy/proposal given herein are correct to the best of my

knowledge.

Details of the *policy/proposal :

(i)

Address of the Branch office or unit of the Life

Insurance Corporation where the policy account * is to be

maintained.

(ii)

*Policy/proposal No. & date.

(iii)

Sum assured/proposal to be assured.

(iv)

Probable date of purchase of the policy

(v)

Whether the proposal has been accepted and if so,

By what date the first premium is to be paid.

(vi)

Cost of the policy (in the case of single payment policies)

Form 14 - Application For Financing A Life Insurance Policy Out Of The Provident Fund Account Page 2

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