First Name
Middle Name
Last Name
Email
Mobile No.
D.O.B.
Residential Status
Resident Indian
Non-Resident Indian
Present country of residence
India
Andorra
Anguilla
Antigua & Barbuda
Aruba
Australia
Austria
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Belize
Bermuda
Bhutan
Brazil
British Virgin Islands
Brunei
Bulgaria
Canada
Canary Islands
Cape Verde
Chile
China
Croatia
Cyprus
Czech
Denmark
Estonia
Falkland Islands (UK)
Fiji
Finland
France
Germany
Gibraltar
Greece
Greenland
Guadeloupe
Guam
Hong Kong
Hungary
Iceland
Ireland
Israel - Tel Aviv
Italy
Japan
Jordan
Kuwait
Latvia
Leichtenstein
Lithuania
Luxembourg
Macau (part of China)
Madeira
Malaysia - Kuala Lumpur
Maldives
Malta
Martinique ( France)
Mauritius
Mexico
Monaco
Nepal
Netherland Antilles
Netherlands
New Caledonia
New Zealand
Norway
Oman
Poland
Portugal
Qatar
Reunion (France)
Romania
Russia-Major cities
S Korea
Saudi Arabia
Seychelles
Singapore
Slovak Rep
Slovenia
South Africa-Bloemfontein
South Africa-Cape Town
South Africa-Durban
South Africa-Johannesburg
South Africa-Pretoria
Spain
Sri Lanka
St Kitts and Nevis
St Lucia
St Martin (France & Holland)
St Vincent and Grenadines
Sweden
Switzerland
Taiwan
Thailand
Trinidad & Tobago (TT)
Turkey
Turks and Caicos
U.A.E
UK
US Virgin Islands
USA
Venezuela - Caracas
Vietnam - Ho Chi Minh City
Kenya
Angola
Whether Employed in LIC
Not Employed in LIC
Existing Employee in LIC
Retired Employee from LIC
Servicing Unit
Choose
----------------------
Bangalore
Chennai
Delhi
Gurgaon
Hyderabad
Secunderabad
Kolkata
Mumbai
Thane
Pune
----------------------
Agra
Ahmedabad
Gandhinagar
Ajmer
Aligarh
Allahabad
Amravati
Amritsar
Asansol
Aurangabad
Bardhaman
Bareilly
Begusarai
Belgaum
Bellary
Berhampur
Bhagalpur
Bhavnagar
Bhopal
Bhubaneswar
Bikaner
Bilaspur
Bongaigaon
Chandigarh
Coimbatore
Cuttack
Davanagere
Dehradun
Dhanbad
Ernakulam
Faizabad
Faridabad
Goa
Gorakhpur
Gulbarga
Guwahati
Gwalior
Haldwani
Howrah
Hubli
Indore
Jabalpur
Jaipur
Jalandhar
Jalpaiguri
Jammu
Jamshedpur
Jodhpur
Jorhat
Kadapa
Kanpur
Karimnagar
Karnal
Kharagpur
Kolhapur
Kottayam
Kozhikode
Kurnool
Lucknow
Ludhiana
Madurai
Mangalore
Meerut
Muzaffarpur
Mysore
Nadiad
Nagpur
Nanded
Nashik
Nellore
Noida
Patiala
Patna
Pondicherry
Raipur
Rajahmundry
Rajkot
Ranchi
Rohtak
Salem
Sambalpur
Satara
Satna
Shahdol
Shimla
Silchar
Surat
Thrissur
Tirunelveli
Trichy
Trivandrum
Tuticorin
Udaipur
Vadodara
Varanasi
Vellore
Vijayawada
Visakhapatnam
Warangal
I hereby confirm that the mobile number provided by me is registered in my own name. By ticking this box, I hereby authorize Life Insurance Corporation to call me back to assist and verify the information provided by me even if I am registered in the DND of TRAI
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