PART-II
PERSONAL LOAN TO LIC AGENTS
(For Common Application Form, Guarantor’s Consent Letter & Acknowledgement-Please fill PART-I)

A. DETAILS OF PROFESSION
Address& telephone No of Office

No of Years As LIC Agent ________years.
Agency No.
Monthly Commission earned
Monthly Statement is enclosed.

B. DETAILS OF ASSETS AND LIABILITIES
ASSETS AMOUNT LIABILITIES AMOUNT
1. Deposits with Banks 1. Borrowings from LICI.
2. Post Office Deposits 2. Borrowings from Banks/financial Inst.
3. NSCs 3.Any other Liabilities
4.Shares/debentures
Bonds/Units
5. Gold & Jewellary
6. Investment in Business
7.Immovable Properties
TOTAL TOTAL

DETAILS OF FINANCE REQUIRED
1. Loan amount required Rs.
2. Purpose of Loan
3. Proposed Repayment in _________Years.
4. Whether Installments will be paid by applicant directly YES/NO
5. Whether Post dated cheques for repayment will be given YES/NO

I submit the following papers / documents in support of my above submission
(Please mark tick against each)
1. Commission Sheet for the month of____________.
2. Undertaking from LIC of India
3. Post Dated Cheques of ________ leaves.
4. Guarantors consent letter
5. Authority letter to LICI to remit the commission to bank.

Signature of the Applicant Signature of the Joint-Applicant
Place
Date