Page 1 of 3
I,_______________________________________________________________________________
The Assured under the within Policy ; hereby nominate under section 39 of the Insurance Act, 1938,
My (relationship) ___________________________Named _________________________________
Aged _____________________years and whose address is ________________________________
As the person to whom the moneys secured under the Policy shall be paid in the event of my of
death.
Signed at __________________________this______________________ day of____________2000
WITNESS
( Signature in English) ( Signature of Life Assured)
Full Name :___________________________ "Certified that the contents of the above
nomination hace been explained by me to
the Assured _________________________
In vernacular and that he/she affixed his/her
Designation :__________________________ Signature/thumb impression thereto in my
presence afther throughly understanding the
same".
Address :_____________________________
_____________________________________
(Signature of witness)
(Seal)
Page 2 of 3
INSTRUCTIONS
1. A Nomination can be made only by the holder of a Policy on his own life, i.e. only by the Life
Assured.
2. After filling up the blanks as may be necessary in the form of Nomination printed on the
reverse, the Assured should copy it out on the back of the policy. The certificate of the
witness should also be copied out if the signature of the Life Assured is not in English (see 3
below).
3. The Assured must affix his signature to the endorsement in the presence of a witness. If the
Assured be not conversant with English, he/she should sign the endorsement before an
English knowing witness and if he/she be illiterate he/she must affix his/her thumb impression
to the endorsement before a Magistrate, S.E.M. 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 officers
recruited from agents who were ZM or Chairman's club members 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 be 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
Assured's death during the minority of the nominee. A form of Appointment of Appointee with
instruction can be had from the corporation on application.
F No. 3264
NRPP/500x100/5/96 Padsx100/2/95