L.I.C.OF INDIA DIVISIONAL OFFICE 16/275, CIVIL LINES, KANPUR APPLICATION FORM FOR EMPANELMENT OF FIRM

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1 L.I.C.OF INDIA DIVISIONAL OFFICE 16/275, CIVIL LINES, KANPUR APPLICATION FORM FOR EMPANELMENT OF FIRM (Last date for submission of application up to 3.00 pm) As per list mentioned on Page No. 3 & 4 Annexure A SL.NO.OF CATEGORY NAME OF CATEGORY/ITEM (Separate application is to be filled up for each category or Specific item in the category) Conditions for Empanelment 1. The firm/supplier should be in profession for at least 3 years. 2. The Firm/supplier should have registration with state & local authorities for Undertaking the profession (copies of proof to be enclosed). 3. The firm/supplier should keep sufficient stock in hand so as to comply with the Urgent needs without delay. 4. The printer should have sufficient space for operating printing, binding and other activities and sufficient storage space at one place only. 5. Application forms can be downloaded from our website (tender page) or the same can be obtained from the Office Services Department L.I.C.OF INDIA DIVISIONAL OFFICE 16/275,CIVIL LINES,KANPUR on payment of application fee of Rs. 100/- in cash or by making payment in the form of demand draft favouring Life Insurance Corporation of India payable at KANPUR. Last date for receipt of application forms duly completed is up to 3.00 pm. 6. Application for empanelment duly completed should be submitted at the above address in a closed envelop super scribed as Application for empanelment of suppliers/vendors/category Sr. No. & name of category/item 7. In case, the application has been downloaded from our website it needs to be accompanied by Bank DD/Pay order of Rs.100/- in favour of LIC of India payable at KANPUR for each category.

2 8. Mere submission of Application for empanelment does not confer the right of Empanelment. Life Insurance Corporation of India reserves the right to reject, accept any or all applications or cancel the process of empanelment without assigning any reason thereof for which Life Insurance Corporation of India shall neither be liable nor it will be obligatory to inform the applicant the grounds of any such action. (The information furnished in the application would be scrutinized /checked by our officials). 9. The firms/suppliers who are on our panel are required to apply for fresh empanelment if interested. 10. Firms/suppliers who have been black listed / removed earlier, should not apply. If applied, their applications will not be considered. 11. All applicants are required to affix the signature and seal of the Authorised official of the Company /Firm on the each page of Annexure B in acceptance of terms and conditions therein Sr. Divisional Manager

3 Empanelment of Supplier/Printer/Manufacturers Annexure A Applications are invited from reputed manufacturers / printers / vendors / service Providers for empanelment for following items SL.NO. CATEGORY 1 Supply of Table Stationery & Office Stationery such as pens, files, A-4 size paper, Punching Machines, Staplers, Office Envelops of Varied sizes, Flat files, Plastic Wallets, Dockets & Envelops Printed Stationery, Computers Consumables stationery & Policy Bonds etc., 2 Offset/ Screen printers for printings of forms, letter heads, leaflets, pamphlets,visiting cards, etc. 3 Supply of water coolers (make: Voltas, Blue Star, Usha ), Air conditioners (Make: Voltas, Blue Star, Hitachi & Carrier), Water Purifier. 4 Supply of Air Coolers of approved brands, heaters, blowers, other electric appliances for office use like Refrigerators, wall fans, tube lights chokes, CFL etc. 5 Supply of Stabilizer, Servo Stabilizers, Inverter And Inverter Battery 6 Data cable related works. 7 Annual maintenance contract of water coolers,air conditioners, Water purifier, Servo stablizers 8 For repair and maintenance of Electrical works(enclose copy of Electrical License) Category wise 9 For repair and maintenance of Civil works ( Category wise) 10 Supply and Maintenance of CCTV systems. 11 Supply and installation of Fire Alarm Systems. 12 Supply of office furniture, like Modular/Non Modular chairs, tables,docket size racks, filing racks, cabinet, sofa of good quality etc.(make of approved and good reputed firms) 13 For Fire fighting/hydrant related jobs 14 Supply of Note counting & fake note detecting machine(approved & good firms). 15 Annual maintenance contract of Note counting Machines 16 Repair work of Wooden, Iron & office furniture including polishing of wooden furniture 17 Cleaning of furniture and office curtains (Vertical Blinds),Washing of bed sheets, towels etc.

4 18 To Purchase of Waste office papers, Unserviceable items etc for disposal 19 Supply of Office upkeep Material such as Branded phenyl, Soap, Detergent, Chemicals, broom, duster, Deodorant for toilets, Disposable gloves, Caps, Masks etc 20 Courier Services 21 Photo copier services 22 Installation of EPBAX & its maintenance 23 Cleaning of telephone set & computer monitor, key board etc. with approved brands of anti-bacterial agents 24 Pest Control services with approved Chemicals for Antimosquito, Anti-rodent, and anti -termite etc treatment 25 Other office services Cleaning of office Toilets and corridors, gardeners,housekeeping services for Guest Houses etc 26 Security Services Signature : Name : Designation : Seal of firm :

5 ANNEXURE B APPLICATION FOR FIRM/SUPPLIER/SERVICE PROVIDER GENERAL INFORMATION DETAILS INFORMATION PROVIDED Name of the Firm (In Block Letters) Date of Establishment / Incorporation of the firm Correspondence address and Telephone No, E_Mail address Address of Head Office (if Separate) and Telephone No., E_Mail address Address of Local Office ( AT Kanpur ) and Telephone No., E_Mail address Give details of business / Profession Details of products available / services provided by you. ( separate sheet / letter head for giving details may be attached) Status Proprietary/Partnership Limited company/public Limited Company. Names of the Partners/Directors and their mobile nos.

6 Name of Chief Executive, address, Telephone No. Name of Representative(s) indicating Designation who would be calling on us and attending to our jobs ( Telephone No./ Mobile No.) Whether registered at small/ micro/ medium enterprise within relevant Authority, if yes, please enclose the certificate If the firm owned by SC/ST or General entrepreneur Name of Chief Executive with his Present addresses and Telephone Nos. Name of Representative (s) with Designation who would be calling on us and attending to our jobs Name of bankers with addresses & Telephone No s. Is the firm registered under the Factories Act? If yes, state (a) Licence No. (b) Date of renewal of License (copy of licence to be enclosed Please give the following details: (a) PAN No. (b) VAT(TIN No.) (c) Service Tax No. (d) ESI No. if any (e) EPF registration No. if any (f) Labour licence No. Whether holding certificate under shops & establishment act, duly Renewed copy should be enclosed. Give the latest Income Tax Assessed year and the amount of tax assessed (copies of last 3 years, IT Returns need to be enclosed)

7 Turnover for last three years Whether Black listed by any Govt. Deptt. / Public Sector Company Do you agree to make deliveries to the Corporation Divisional Office, Kanpur Are you agreeable to abide strictly by the Terms and Conditions of the Tenders and Contracts Total No. of employees Permanent Temporary Skilled Non skilled Number of shifts you work normally Timing of shifts Weekly Holidays If your firm is empanelled with Any of office of LIC of India or any Other PSU (Central) Please give name And Address. Name, Addresses and Telephone Nos. of some of your most valued Clients ( Separate list may be attached Mention any other specialties of Your Establishment

8 Bank DD/Pay Order/Cash Receipt No. of application fee of Rs.100/- Note: Please type this form or fill it legibly in ink. If space provided is insufficient, please type or write the replies on a separate sheet giving appropriate question number and attach it to the form. All the pages of application Form and documents must be signed with seal DECLARATION 1. I/WE request Life Insurance Corporation of India, Divisional Office, KANPUR to Consider inclusion of my/our name in the list of their approved firms/suppliers. We agree to give full satisfaction to the Corporation in the event of their doing so. 2. I/We have read the instructions and I / We understand that the information furnished now is found false at a later date, any contract made between ourselves and the LIC, on the basis of the information given by me solely responsible for the consequences. 3. I /We agree that the decision of the LIC in selection of Firm/Suppliers/Service Providers will be final and binding on me / us. 4. All the information furnished by me hereunder is correct to the best of my / our knowledge and belief. 5. I/ We agree that I/We have no objection if inspection of my / our premises / workshop / shop etc. is done by the Officials of the LIC. Dated at this day of 2017 Signature : Name : Designation : Seal of firm