Date : 10/06/2015

To,
Delhi DO-1,
Zonal Office,
LIC OF INDIA
Jeevan Prakash Building,
25, K.G. Marg, New Delhi-110001

Sub. : Regarding the LIC Policy of alongwith another policy of undersigned Vide
Proposal No. 643 and 1128 respectively.

Dear Sir,

This has reference of query raised by you as follows :-

1. As per your first requirement for duly filled Form-300 for PWD-SPL Report, here I am
submitting the dully filed Form-300 with Special Medical Report for LIC Proposal No. 643.

2. The information stated in Q. No. 7 whether the father having any policy through any private
or Govt. Insurance. I hereby declared that I have only one policy Vide No. 117797461 from
the LIC of India (Receipt is attached for reference)

3. Latest school going I.D. Card for the session 2015-2016 is attached; and Child Height is
135 c.m. and Weight is 35 KG, the medical report of child HT/WT is attached.

4. In respect of details of Insurance of other Child Life; it is submitted that the name of my
second child does not have any Policy from LIC of India or any other Pvt. Insurance. So
there is no need for providing you the details of policy for my second child.

5. Form-16 duly signed by employer, here I am already submitting the Form-16 for F.Y. 2011-
12, 2012-13 in original, and Form-16 of F.Y. Year 2013-14 was stolen so here I am
submitting you the my Salary Account Statement for F.Y. 2013-14, and 2014-15 and same
is attached.

6. All the policies being financed by Father in all lives, so here I want to tell you that there are
no any other policy financed by me for my child Lives except the LIC proposal No. 643.
Details of Policy are as under:-

Sl. Policy No. Name of Policy Relation Sum Assured Premium

No Holder
.
1. 117797461 Satish Kumar Self Rs. 5,00,000/- Rs. 11,385/-
2 Proposal No. 643 Saprsh Kumar Son Rs. 8,50,000/- Rs. 14,997/-
3. Proposal No. Satish Kumar Self Rs. 3,10,000/- Rs. 7,620/-
1128
4. Sushila Kumar Wife Nil Nil
5. Shrishti Kumar Daughter Nil Nil

I request you kindly accept the abovesaid submission for allow and issue the LIC Policy
under the Lic Proposal No. 643 and 1128.

Thanking you
 Satish Kumar
Proposer
LIC Proposal No. 643

CC:
Branch Manager
LIC OF INDIA
11F
 Date : 19/06/2015
To,
Delhi DO-II,
Zonal Office,
LIC OF INDIA
Jeevan Bharti Building,
124, Connaught Circus, New Delhi-110001

Sub. : Regarding the LIC Policy of alongwith another policy of undersigned Vide
Proposal No. 643 and 1128 respectively.

Dear Sir,

This has reference of query raised by you as follows :-

1. As per your first requirement for JFMR through TPA Report, here I am submitting the
JFMR through TPA Medical Report for LIC Proposal No. 643.

2. Complete progress report for year 2014-15 of Child is attached.

3. Copy of cancelled cheque is attached.

I request you kindly accept the abovesaid submission for allow and issue the LIC Policy
under the Lic Proposal No. 643 and 1128.

Thanking you

Satish Kumar
Proposer
LIC Proposal No. 643

CC:
Branch Manager
LIC OF INDIA
11F