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LIFE INSURANCE CORPORATION OF INDIA
NAVY PERSONNEL QUESTIONNAIRE
Proposal No_______________________ Form No. LIC03 - 505
Name of the Life to be assured_____________________________________________
1. Give particulars regarding the branch of the Naval Forces, etc. to
which you belong and your present rank?
2. A. Are you at present engaged in:
a. Any flying duties as a pilot or member of aircrew or
other duties requiring you to remain on board an aircraft
otherwise than as a passenger for the purpose of
transport
b. Duties as a paratrooper
c. duties as a Glider pilot or
d. duties as a member of aviation operating personnel or
ground personnel
B. Were you engaged in the past in any of the duties mentioned
under (A) above, and if so, are you likely or liable to return to
the same in future?
C. Have you undergone or are you now undergoing training for
any of the duties mentioned under (A) above?
D. Have you, under the terms and conditions, of your service, any
special liability to engage in Aviation, Gliding or Parachuting?
N.B. - The liability referred to herein is not the general liability
imposed on all Defence Service Personnel in terms of which they can
be called upon to make up any type of work in any of the Defence
Services.
3. Are you a member of any Flying or Gliding Club? If so, state:
a. whether you are undergoing training in flying or gliding or
whether you have completed such training?
b. the number of flights made per annum

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4. A. Have you ever been or do you intend to or are you liable or
likely to be engaged to do any work in a submarine, Mine-
layer or Minesweeper and if so, in what capacity?
B. Have you received any training or are you liable or likely to
receive any training to work in a submarine, mine-layer or
Mine-sweeper? If so, give details
5. A. Have you ever been required to or do you intend or are you
liable or likely to do diving in the course of your duties?
B. State the maximum depth upto which you have dived or have
been trained to dive and number of dives undertaken during
the last 12 months
DECLARATION
I ___________________________________________ do hereby declare that the foregoing
statements and answers are true in every particular and agree and declare that these
statements and this declaration along with my Proposal for Insurance and the Declaration
relative thereto shall form the basis of the contract between me and the Life Insurance
Corporation of India and that if any untrue averment be contained therein the said contract
shall be absolutely null and void and moneys which shall have been paid in respect thereof
shall stand forfeited to the Corporation.
Dated at _____________on the _________day of _____________200
Signature of Witness__________________
Occupation
Address Signature of the Life to be assured
In case the Proposer is illiterate:
1. This declaration should be made by the person filling in the form:
I hereby declare that I have fully explained the above questions to the proposer & I have
truthfully recorded the answers given by the proposer.
Address of the Declarant Signature
______________________
2. The thumb impression of the proposer should be attested by a person of standing whose
identity can be easily established, but unconnected with the Corporation and this declaration
should be made by him:
I hereby declare that I have explained the contents of this form to the proposer in
__________(language) and that I have read out to the proposer the answers to the questions
dictated by the proposer and that the proposer has affixed his thumb impression to this form
after fully understanding the contents thereof.
Address of the Declarant Signature
______________________

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Navy form lic03-505

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Navy form lic03-505