(Established by the Life Insurance Corporation Act, 1956)

Form of Nomination Under Jeevan Saathi Policy We

(Form No. 3237-A) the

lives assured under the within policy, hereby nominate under Sec.39 of the Insurance Act, 1938 our( relationship) and whose address is : named aged years

as the person to whom the moneys secured by the within policy shall be paid in the event of Death of both of us either simultaneously or one after the other at any time before the date of maturity under the within policy . Dated at , on the day of 20 .

Signature of Witness : ______________________________

1. _______________________________ 2. _______________________________ ( Signatures of Lives Assured )

Full Name : ___________________ Designation :___________________ Address : ___________________

Certified that the contents of the Nomination have been explained by me to the life/lives assured in Vernacular and that he/she/they affixed their signature(s) thumb impression(s) thereto in my presence, after his/her/their thoroughly understanding the same. _______________________________ ( Signature of Witness ) ( Seal )

( See Instructions)

Form of Nomination Under Jeevan Saathi Policy (Form 3237-A)

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INSTRUCTIONS (1) A nomination can be made only by the holders of a Policy on their own lives, i. e. only by the Lives Assured. (2) After filling up the blanks as may be necessary in the Form of Nomination, the Lives Assured should copy it out on the back of the Policy. The certificate of the witness should also be copied out if the signature/s of any or both lives assured/s is/are not in English ( see 3 below ) . (3) The Lives Assured must affix their signatures to the endorsement in the presence of a witness. If one or both the Lives Assured be not conversant with English, he/she/they should sign the endorsement before an English knowing witness and if he/she/they be illiterate he/she/they must affix his/her/their thumb impression(s) to the endorsement before a Magistrate, Justice of the Peace, a Special Executive Magistrate, a Gazetted Officer. An Officer or Development Officer of at least 3 years standing or Confirmed Development officer recruited from the Agents, who were DM or BM club members before joining or Development Officers recruited from agents who were ZM or Chairmans club members before joining provided he / she is fully satisfied about the identity of the person(s) executing the endorsement. In such cases the witness should sign the certificate in the endorsement. (4) Immediately after a Nomination has been effected by an endorsement, the Policy must be sent to the Servicing Office of the Corporation for registration of the Nomination. A nomination will NOT be effectual unless it is communicated to and registered by the Corporation. (5) If the nominee is a minor, it is advisable to appoint in the manner prescribed by the Insurance Act an Appointee to receive the moneys secured by the Policy in the event of the simultaneous death of the lives assured etc. during the minority of the nominee. A form of Appointment of Appointee with instruction can be had from the Servicing office of Corporation on application.

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Form of Nomination Under Jeevan Saathi Policy (Form 3237-A)

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