Sr. No.

                  Particulars

1.

Yours Nationality

2.

a.

Your country of permanent residence

b.

Date from which you became a permanent resident of country mentioned in (a) above

3.

a

Date of leaving India for the first time

b.

Details of exchange facility availed of

c.

Full particulars of Reserve Bank Permit Number

d. 

Visa status, if any

e.

Name of Office of the Reserve Bank which granted the above facilities

4.

Duration of your stay abroad

5.

a.

Purpose of your stay abroad

b.

Are you gainfully employed abroad?

c.

Your monthly income from employment in the foreign country (including Scholarship, Assistantship etc for students or trainees). Please enclose true copies of the appointment letter received from your employer or educational institutes.

6.

a.

Passport Number

b.

Date of issue

c.

Place of issue

d.

Date of birth

7.

Whether you hold any Bank account in India and if so, whether it is a Resident Account or Non-resident Account. Furnish full details thereof

8.

The source from which the premiums will be paid

9.

Please indicate by which of the following manner you propose to remit the premiums to LIC of India

a.

By direct remittance from the country of your residence to India through Banking channels (preferably by Rupee Draft in favour of LIC) Or by remittance through postal channels like foreign orders.

b.

By cheques drawn on your Non-Resident (External) or Foreign Currency (Non-Resident) Account with Bank in India

c.

By cheques drawn on your Resident / Non-resident Account with bank in India

d.

By cheques drawn on account maintained by resident parent or spouse of the policyholder in their name or joint name with other close relatives

e.

By any other manner (please specify)

10.

Your full address in the country of your residence abroad

11.

State full name and address of an Indian National permanently residing in India to whom the policy may be dispatched

12.

Date of your leaving India / Date you left India (current visit)

13.

If you are a student state the nature and full details of your studies