Empanelment Letter

APPLICATION FOR:
EMPANELMENT OF
VENDOR/FIRM/SUPPLIER/SERVICE PROVIDER
GENERAL INFORMATION Annexure-B
SL NO
1
INFORMATION SOUGHT INFORMATION PROVIDED
Name of the Firm ( in Block Letters)
2 Date of Establishment/Incorporation
3
Correspondence Address and
1. Telephone Number
2. Mobile Number
3. E-mail ID
4
Address of Head Office (If separate) and
Telephone number
5 Status : Proprietorship/ Partnership/
Private Limited Company/Public Limited
Company
6 Name of Partners/Directors
7 Name of Chief Executive with present
address and
Telephone / Mobile Number
Name of Representative (s) with
Designation who would be calling on us
and attending to our jobs.
Name of Bankers with addresses &
telephone numbers.
10 GST REGISTERED NUMBER (if registered)
Is the
Firm/establishmentregistered
under the Factory Act ? If so,
state Please
a) Licence Number
b) Date of last
renewal of licence(
copy of licence to be enclosed )
c) P.A.N.
d) ESINumber, if any
e) EPF Registration No. If any
Whether holding certificate under Shops
12 &
Establishment Act, duly Renewed Copy
(to be enclosed).
13 State the latest Income Tax
Year and the amount of Tax
Assessed
assessed.(
Copies of last 3 years, IT Returns, Balance
Sheets & Revenue Account to be
enclosed)
14 Turnover for the last three Financial
Years
F.Y. 2018-19, 2019-20 & 2020-21
F.Y. 2019-20, 2020-21 & 2021-22 (if

finalized).
15 Are you agreeable to make deliveries to
Corporation's Offices within and outside
of LUDHIANA as & when so directed?
16 Are you agreeable to abide strictly by the
Terms and Conditions contained in
Notice of Empanelment? (Please attach
annexure).
17 If Your Firm is empanelled with any
office of LIC Of India or any other
Central/State Government Unit/PSUs,
Please give name and addresses. Attach
copies of Work orders/ certificate from
such Central/State Government
18
Units/PSUs.
Name, Addresses and Telephone
Numbers of somne of your most valued
clients.
(You may attach Separate Lists)
19 Approximate value of Output Per Annum
of Establishment.
20 Mention any other specialties of Your
Establishment/Firm
NOTE: Please type this form or fill it legibly in ink. tf space provided is insufficient, please type or write
the replies on a separate sheet giving appropriate question number and attach it to the form.
Allthe pages of application form and documents must

be signed with seal.
SIGNATURE WITH SEAL
AND DATE
TERMS AND CONDITIONS OF EMPANELMENT
1. The Firm/Suppliers/Printers/Service Providers must submit the application
form/enrolment form duly completed in all respects. No question of the application

form should be left blank. Dots/dashes will not be accepted as answers.
2. The Firm/Supplier/Service Provider should be in profession for at least 3 years. The
Firm/Supplier/Printers/Service Provider should have registration with state/ local
authorities for undertaking the profession (Copies of State Registration to be enclosed).
3. The Firm/Printer/Service Provider should be on the approved panel of at least 3
reputed firms out of which at least one should be Public Sector or Govt. undertakin8
4. The Firm/Suppliers/Printers/Service Providers must submit duly self-attested Income
Tax returns for the last three financial years along with Trading and Profit & Loss
account. The turnover of the financial years must be clearly available the above
statements.
5. The condition of Minimum Average Annual Turnover of last three years will be strictly
followed.
Average Turnover may be for the financial year 2018-19, 2019-20 &2020-21 OR
2019-20, 2020-21, &2021-22 (if finalized).
6. Vendors should furnish the specific brand or make, if required, and in case of authorized
dealer (Copy of Valid authorized dealership certificate must be enclosed.)
7. All the Firms/Suppliers/Printers/Service Providers have to apply for fresh appointment.
All the Firms/Suppliers/Printers/Service Providers who have been black listed/debarred/
de listed /removed from panel, should not apply. If applied, their application will not be
considered.
8. The Firms will be empanelled only after positive recommendation of committee duly
constituted to scrutinize, visit and inspect the premises / workshop etc. of the applicants
and approval of competent authority.
9. Allapplicants are required to affix the signature and seal of the Authorized official of
the Company/Firm on each page of Annexure "B" in acceptance of terms and
conditions therein. Both Declaration Forms (Declaration l and li) duly filled in, signed
and stamped must be appended with the application form.
10. It has been mutually agreed between the Corporation and the vendor/firm/company
that any dispute arising out of this acceptance shall be referred to for "Arbitration" to
the Senior Divisional Manager, LIC of India, Divisional Office, Ludhiana of the
Corporation and his decision shalI be binding on the vendor/firm/company. The
vendor/firm/company shall not raise any question of competence of the Senior
Divisional Manager to act as sole arbitrator.
11. Mere submission of application for empanelment does not confer, in any way, any right
on the applicant to claim empanelment. Sr. Divisional Manager, Ludhiana reserves the
right to accept or reject in full or part any application, without assigning any reason
thereof.
12. All the above terms and condition are not exhaustive. It is subject to change according
to the circumstances by the Corporation.
Sr. Divisional Manager

DECLARATION -I
I/We agree to notify the
officer accepting this application and
registering my/our names on list of Firms/Service
Life Insurance
Corporation Providers/Vendors
Of India, of any changes
of
particulars as and when they occur and to verify andin the foregoing
annually on 1 January. confirm these
I/We understand agree that the
of India Authority has the right appropriate Life Insurance Corporation
as he may decide, not to issue
form in any particular case and also to tender
suspend, remove or
my/our name from Life Insurance Corporation Of India's blacklist list of
firms/Suppliers/Service Providers/Vendors in the event of my/our
submitting non-bonafide tenders or for technical or other
in regard to which the decision of delinquency
appropriate Life Insurance
Corporation Of India Authority shall be final and conclusive.
I/We certify that the particulars furnished in the enrolment forms are
correct and that should it be found that \/We have given a false
certificate or that if I/We fail to notify the fact of my/our subsequent
amalgamation with another contractor or Firm, the Life Insurance
Corporation Of India may remove my/our name from the list of
Firms/Suppliers/Service Providers/Vendors and any contract that I/We
may be holding at the time may be rescinded.
PLACE:
DATE SIGNATURE WITH SEAL
AND DATE
DECLARATION -II
Official of the M/S proprietor/partner/director/member/authorized

do
hereby solemnly affirm and declare as under:
1. That Iam the duly authorized official to give the following declaration.
2. That the business Concern is in the profession of
for the last three financial years.
3. That the business concern has not been debarred/de listed/Black Listed in the
last three years.
4. That there have been civil suit/litigation/arbitration cases arisen during
the last five financial years, in the contracts including orders regarding
exclusions/expulsions or black listing.
5. That in case the business concern is found to indulge in any foul practice such as
pooling etc. the department can take any disciplinary action as debarring and
cancellation of registration/empanelment as deemed fit by the department.
6. Isolemnly declare that the statements made above are true and correct to the
best of my knowledge and belief.
Signature and Seal of the Business Concern

Date : Place

Empanelment Letter

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APPLICATION FOR:

F.Y. 2019-20, 2020-21 & 2021-22 (if

Allthe pages of application form and documents must

SIGNATURE WITH SEAL

form/enrolment form duly completed in all respects. No question of the application

Sr. Divisional Manager

Official of the M/S proprietor/partner/director/member/authorized

Signature and Seal of the Business Concern

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