KEYMAN QUESTIONNAIRE

LIFE INSURANCE CORPORATION OF INDIA

Name of Division :

                                                                                            Proposal No.  :

KEYMAN QUESTIONNAIRE

1. Name of the Employer Company

2. Detailed Nature of Business/activities of the company

3. (a) Name of the Keyman

    (b) His date of Birth

4. (a) Status/Occupation of Keyman

    (b) Give full details of the Keyman's duties

5. His academic and Professional Qualification

What special knowledge / expertise does Keyman possess or why the Company is so dependent on him.

6. What basis has been used to arrive at the sum proposed ?

7. State Employer's turnover and gross & net profit over           Year

     the last 3 years.                                                                    ___  ____  ____   ____          

Turnover         

(G.P. = N.P. + Tax  + Depreciation)                

(Replies such as "as per balance sheet P & L A/c          G.Profit

enclosed" not acceptable. Summary must                      Net Profit

be given here)

8.         What are the realistic immediate & future prospects of the Keyman ?

9.         Give details of the Keyman's salary                               Year

(Including commission payment/profit 

sharing etc) bonus earned by him                                   Salary  :

during last 3 years.                                                        Value of          

perks if

                                                                                                any:                                         

10.       Is the Keyman or any member of his family                    No.of               % of the total

            is a shareholder. What is the holding in                           Shares held      Shares issued   

            relation of the total issued capital ?       

                                                           

                                                                                    Keyman :

                                                                                    Spouse :

                                                                                    Minor     :

                                                                                    Children :

                                                                                    Total     :

11.       What are the details of the Keyman's Service Agreement ? 

Attach copy of the agreement also.

12.       Has the Board authorised the purchase of  policy ? If so, attach the original copy of

            Board Resolution.

13.       What is the normal retirement date of the Keyman.

14.       (a)        Does the Company already       Name of           Pol.No. DOC    S.A.          Whether

                        hold any Keyman policies ?       Keyman                                                      inforce

            (b)        Has the Company simultaneously

                        proposed KMI on the lives of any

                        other key personnel ?

                        If so, give details ?

            (c)        Does company intend to

                        effect keyman insurance

                        policies on the lives of

                        any other key personnel ?

                        If so, give details.

15.       Whether the above employee is also considered as Keyman in any other Company ? If so, give details thereof.

16.       What permanent health or other sickness insurance arrangements have been/will be made for the Keyman.

17.       if the company is an unquoted Public Limited Company or a private Limited Company, give following details

            I)          Total No. of shareholders

            II)        Total No. of employees

Place    :

Date     :                                                          

Signature of Official