FORM OF ASSIGNMENT OF POLICY FOR VALUABLE CONSIDERATION

(Absolute Assignment)

Note : THIS FORM SHOULD NOT BE FILLED IN. The wording of the form, if found suitable,
should be copied out either on the back of policy itself, or in the alternative, on a proper stamp
paper of the requisite value.

(FOR INSTRUCTIONS RE: EXECUTION OF AN ASSIGNMENT SEE REVERSE)

I, in
Consideration of the sum of Rupees
Paid to me by

the receipt Of which I hereby acknowledge, do hereby as beneficial owner assign unto the said
Aged years his Heirs, Executors

Administrators and Assigns the policy Of Assurance on the life of myself granted to me by the
Life Insurance Corporation of India assuring the sum of Rupees

And numbered and bearing date

the day of 1999 /2000 and the sum assured thereby and all other moneys
benefits and Advantages to be received thereunder.

Dated at this day of year 2000

WITNESS :

Signature :- ______________________________

Full Name :- ______________________________ _________________________

Signature of Life Assured

Designation :- _____________________________

Address :- ________________________________
 Place : _____________________

Date :- _____________________

The Senior / Branch Manager,

Branch No. ________________
Life Insurance Corporation of India,

Policy No. ________________________Own Life

Dear Sir,

I hereby give you notice that I have assigned the above policy to :

Shri. ________________________________________
____________________________________________
_____________________________________________
_____________________________________________ } Here mention the name and
address of the assignee.

On ___________Please acknowledge receipt of this notice and forward the enclosed Policy/Deed
Of Assignment to ___________________after registering the assignment thereon in your Books

Certified that the thumb impression here in is

That of _______________________________________________

Who admits having affixed the same after understanding the

contents hereof

Yours faithfully

___________________________

Signature of Witness (Signature/Thumb Impression of Assignor)

 NOTE

?? Notice Should be given by assignor or his/her duly authorised Agent.

The assignor's thumb impression to the form should be attested by a Magistrate or justice of the
Peace or a Gazetted Officer. An officer or Development officer of atleast 3 years standing or
confirmed Development Officer recruited from the Agents, who were DM or BM club members
before joining or Development officer recruited from agents who were ZM or Chairman's club
members before joining Provided he / she is fully satisfied about the identity of the person. The
attesting witness should certify as above

INSTRUCTIONS
(1) After making such alteration, if any as may be deemed necessary in the case under
consideration, the form printed on the reverse should be copied either on the back of the
policy, in which case no stamp duty will be payable or on a separate (Special adhesive or
non-judicial ) Stamp paper of the appropriate value. Parties to the Assignment should satisfy
themselves before forwarding the policy or the Deed of Assignment, as the case may be as
regards proper Stamp duty having been paid thereon.

(2) The full name, and age, of the Assignee must be stated.

(3) The actual consideration for the assignment received from the assignee should be written in
words, not in figures.

(4) The Assignor must affix his signature to the Assignment in the presence of a witness other
than the Assignee. If the Assignor is not conversant with English, he must sign the
Assignment before an English-knowing person and if he be illiterate, he must affix his thumb
impression to the Assignment before a magistrate a justice of peace or Gazetted Officer. An
Officer or Development Officer of Atleast 3 Years standing or confirmed Development Officer
recruited from the Agents, who were DM or BM club members before joining or Development
Officer recruited from Agency who were ZM chairmans club members before joining provided
he/she is fully satisfied about the identity of the person executing the assignment. The
Witness in such cases should certify as follows :-
" Certified that the contents of the above Assignment were explained by me to the Assignor
Mr.____________________________in Vernacular and that he affixed his signature / Left
thumb impression there to in my presence after thoroughly understanding the same.

(5) Signature or any other matter written in Vernacular should have the english translation therof
written beneath the same.

(6) Immediately after an assignment has been executed the Policy or the deed of Assignment
must be sent to the Divisional Office of the Corporation at________________________
__________________________for registration of the assignment accompanied by anotice in
writing of the assignment. Preferably in the form printed on the reverse. Except as otherwise
provided any law in force at the place where the policy moneys are payable in terms of policy
contract. An assignment other than one in favour of the corporation will not me be operative
as against the corporation(and will not confer upon the assignee or his legal representatives
any right to sue for the policy moneys) unless a notice in writing of the assignment and the
policy bearing the assignment or the assignment deed in original or the copy of the
assignment certified to be correct by both the assignor and the assignee or by the duly
authorised agents are delivered to the corporation and priority of claims under the
assignment will be governed strictly by the order in which notices of assignment have been
received at the divisional office of the corporation through which the policy is issued and not
by dates of execution of assignment.
(7) When the policy is to be assigned by way of security or mortgage only and not absolutely it is
advisable to consult a legal advisor as to form of assignment to be used, amount of stamp
duty etc.

Form No. – 3848

p.i./15,000 f / 12-99