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Revive Postal Life Insurance Policy

The document is an application form for the revival of a postal or rural postal life insurance policy. It requests information such as the name and contact details of the policyholder, policy number, sum assured, dates of acceptance and maturity, premium payment frequency, period of unpaid premiums, reason for non-payment, and preferred post office for future premium payments. For PLI policies, it also requires a certificate from the employer confirming the policyholder did not take any medical leave during the period of unpaid premiums.

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11K views1 page

Revive Postal Life Insurance Policy

The document is an application form for the revival of a postal or rural postal life insurance policy. It requests information such as the name and contact details of the policyholder, policy number, sum assured, dates of acceptance and maturity, premium payment frequency, period of unpaid premiums, reason for non-payment, and preferred post office for future premium payments. For PLI policies, it also requires a certificate from the employer confirming the policyholder did not take any medical leave during the period of unpaid premiums.

Uploaded by

anon_338738283
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FOR REVIVAL OF POSTAL/ RURAL POSTAL LIFE INSURANCE POLICY

(Please fill in the columns in CAPITAL letters)


1. Name of Insurant (Mr./ Mrs./ Ms.)
First Name

Middle Name

Last Name

2. Communication Address

Village
City
State
3.

Taluka
District
Country

PIN

Particulars of Policy

i. Policy No.

ii. Sum Assured

iii. Date of Acceptance

v. Premium Payment Frequency


Monthly
Quarterly

iv. Date of Maturity

Half Yearly

Yearly

6. Period for which premia is due: _______________________________________________________________________


_________________________________________________________________________________________________
7. Reason for non-payment of premiums if any
________________________________________________________________________________________________
________________________________________________________________________________________________
8. Name of the Post Office at which premia are desired to be paid
i. Name of Sub Post Office
ii. Name of Head Post Office

I hereby declare that I continue to be in good health since the date, the first unpaid premium had become due in
respect of above mentioned policy till this date.
Date:________________
Signature of Insurant
Name:
Phone no.:
Office:
Residence:
Mobile no. :

ONLY FOR PLI POLICIES


CERTIFICATE OF EMPLOYER
Certified that Shri/Smt. _____________________________________________________________________
had not taken any leave on medical grounds for the diseases like Insanity, Epilepsy, Gout, Asthma,
Tuberculosis, Cancer, Leprosy, Diabetes etc. as per medical certificate produced by him from time to time
during the period from the date, the first unpaid premium had become due in respect of PLI Policy
No.______________________________________ held by him till this date.

Date:________________

Signature of Employer
with designation stamp

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