always with U

Odisha Gramya Bank

……………………………..Branch

OGB CLEANLOAN

APPLICATION FORM FOR LIC AGENTS Passport Size Photo

I/We here by apply for a Loan of Rs………………. (Rupees………………………. of the Applicant

………………………...... only, for purpose……………………………

which may kindly be sanctioned. I/We furnish the details as under.

1 / Full name of Applicant
2 / Address of LIC Office to which the Agent is attached
City / District
State / Pin
Phone (Office) / Email ID (Office)
3 / Residential Address
City / District
State / Pin
Mobile No/Telephone No. / Email ID
4 / Personal Information
a / Sex / Male/Female / Marital Status / Married/Unmarried
b / Permanent Account Number
c / Voter ID Number
d / Aadhar No (UID)
e / Driving License No
f / Date of Birth
g / No of Years As LIC Agent
h / Agency No.
i / Monthly Commission earned
(Average of Last 12 Months)
5 / Banking with OGB since
6 / Educational Qualification
7 / Details of Assets and Liabilities
Assets / Amount / Liabilities / Amount
Deposits with Banks / Borrowings from LIC
Post Office Deposits / Borrowings from Banks/financial Inst.
NSCs / Any other Liabilities
Shares/debentures/Bonds/Units
Gold & Jewellary
Investment in Business
Immovable Properties
Total / Total
8 / Details of Finance required(Amt in Rupees)
a / Loan amount required
b / Purpose of Loan
c / Proposed Repayment in / ………………………….Years.
d / Whether Post dated cheques for repayment will be given / YES/NO
9 / Income Statement(Income per month (Commission sheet / I.T. Return/Form No.16 attached)
a / Deductions
Income Tax
Professional Tax
Provident Fund
Insurance Premium
Other statutory deductions
Net Income p.m.
Other Income if any(Proof Attached)
10 / Details of Bank Accounts
a / Name of the Bank/Branch
b / Type/s of the Account
c / Account Number/s
d / Since When
e / Average credit balance for last 6 months
11 / Details of existing Loan from Odisha Gramya Bank/Other Banks
Name of Bank/Branch
Type of Loan Availed
Amount of loan Availed
Present outstanding
Security Offered
Repayment Plan
Amount of Default if any
12 / Personal Guarantee
Name and Address / City / District
State / PIN
Permanent Account Number
Voter ID Number
Mobile
Date of Birth/Age
Net Worth with date

I submit the following papers / documents in support of my application (Please (X)mark ( against each)

a / Commission Sheet for the month of______.
b / Undertaking from LIC of India
c / Post Dated Cheques of ______leaves.
d / Guarantors consent letter
e / Authority letter to LIC to remit the commission to bank.

Place:

Date: Signature of the applicant

Recommendation
Signature of Officer (Advances) Signature of Branch Manager