Buy LIC New Money Back Plan 921 Online Please note: Before filling this form keep your documents ready Aadhar Card, PAN Card, Passport Size Photo and Signature. Please provide your details below: Personnel DetailsYour Name *Your age *Your age25262728293031323334353637383940414243444546474849505152535455Gender *MaleFemalePlace of Birth *Place of BirthAndhra PradeshArunachal PradeshBiharChhattisgarhDelhiGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaAssamMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttarakhandUttar PradeshWest BengalChandigarhPuducherryEducational Qualification *Illiterate8th10th12thGraduatePost GraduateProfessional Degree (BBA, MA, MCA, MBA, B.tech, M.tech, Doctor, Lawyer etc.)Choose your plan below:Policy term *Policy term20/15Policy term 20 years, Premium term 15 yearsInvestment according below: *Sum AssuredPremiumSum Assured wise *Sum Assured wise1 Lac2 Lacs3 Lacs4 Lacs5 Lacs6 Lacs7 Lacs8 Lacs10 Lacs15 Lacs20 Lacs25 Lacs30 LacsChoose Premium mode *YearlyHalf YearlyQuarterlyMonthlyPremium wise *YearlyHalf YearlyQuarterlyMonthlyYearly premiumYearly premium1200024000360004800060000800001000001200001500002000003000004000005000001000000Half yearly premiumHalf yearly premium500080001000012000150002000025000300005000080000100000150000300000500000Quarterly premium *Quarterly premium3000500070009000100001200015000180002500030000400005000080000100000Monthly premium *Monthly premium100020003000500080001000012000150001800020000250005000080000100000300004000050000Parents DetailsFather's Name *Mother's Name *Communication DetailsMobile No. *Email Address *Address *City *State *StateAndhra PradeshArunachal PradeshBiharChhattisgarhDelhiGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaAssamMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttarakhandUttar PradeshWest BengalChandigarhPuducherryMarital Status *Marital StatusMarriedUnmarriedProvide Spouse Name *(Husband/wife name)Job ProfilePresent Occupation *Private JobGovt. JobBusinessProfessional (BBA, MA, MCA, MBA, B.tech, M.tech, Doctor, Lawyer etc.)Self EmployedOthersProvide your company name/work *Exact Nature of Duties *(Ex: Manager, clerk, programmer, helper etc.)Annual Income *Annual IncomeBelow 2 Lacs3 Lacs4 Lacs5 Lacs6 Lacs7 Lacs8 Lacs9 Lacs10 Lacs11 Lacs12 Lacs13 Lacs14 Lacs15 Lacs & aboveLength of Service *Length of ServiceBelow 1 year1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 and aboveAre you Income Tax Assessee? *YesNoLife StyleAlcoholic drinks? *Alcoholic drinks?NoYesNarcotics? *Narcotics?NoYesDo you smoke/consume or have you smoked/consumed tobacco in any form ( cigars, cigarettes, beedis, pan masala etc)? *Do you smoke/consume or have you smoked/consumed tobacco in any form ( cigars, cigarettes, beedis, pan masala etc)?NoYesAny other drugs? *Any other drugs?NoYesWhat has been your usual state of health? *Good (Healthy)Not good (Unhealthy)Your height & weight(In feet)Feet4 feet5 feet6 feet7 feet(In feet)(In inch) *Inch0 inch1 inch2 inch3 inch4 inch5 inch6 inch7 inch8 inch9 inch10 inch11 inch(In inch)Weight *(In KG.)Nominee DetailsNominee Name *Age *Relationship with the Life to be assured *Relationship with the Life to be assuredFatherMotherBrotherSisterHusbandWifeSonDaughterDo You have old LIC's policies number? *YesNoProvide policy numbers *(Provide 9 digit policy no.)Upload your documents below:Upload Aadhar card (front side) *Choose FileNo file chosenDelete uploaded fileUpload Aadhar card (back side)Choose FileNo file chosenDelete uploaded fileUpload PAN card *Choose FileNo file chosenDelete uploaded fileUpload your photo *Choose FileNo file chosenDelete uploaded fileUpload your signature *Choose FileNo file chosenDelete uploaded fileAccept term and conditions below: *I agree and authorise or its representative to verify information and contact me to assist with the purchase and servicing of LIC product.Submit