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Form 14 - Application For Financing A Life Insurance Policy Out Of The Provident Fund Account Page 3

(vii)

Amount of yearly permia.

(viii)

Due date(s) for payment of premium.

(ix)

Date of pyament of last premium.

(x)

Whether age has been admitted. If not state the nature of proof

presented to Life Insurance Corporation.

(xi)

Name(s) of the nominee(s) under Section 39 of the Insurance Act,

1938.

(xii)

Guardian appointed under Section 39 of the Insurance Act, 1938 in

respect of minor nominees, if any.

(xiii)

Details of any previous policy already assigned to the C.B.T,

“Certified that I have not withdrawn any amount previously for

financing out of my provident fund account.”

(xiv)

Remarks.

Date………………….

**Signature or left/right thumb

impression of the member

Certified that this form has been *signed/thumb impressed before me by…………

(Name of member)

Account No………………….. employed………………………………..

(Name of establishment)

Signature of the employer of his

authorised official

Date ……………………

Designation……………………….

Code No. of the Estt……………..

Name and address of the

Establishment and its stamp

* Delete portion if not applicable.

** Left hand thumb impression in the case of illiterate male member and right

hand thumb impression by illiterate female member.

For use in Regional Commissioner’s Office

(Accounts Section)

Please furnish the following information in respect of the subscriber :

Average of yearly

Total contributions

Whether any other

Whether the

contribution

(Employees’ share

L.I.P. Advance

subscriber has

(Employees’ share

only) as on

has been granted

contributed for two

only) on the basis

before, f so,

years.

Form 14 - Application For Financing A Life Insurance Policy Out Of The Provident Fund Account Page 3

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