Customer Information Sheet
Self Checker Form
Life Insurance Form
POSP Details
PAN Number (Optional)
Authorized POSP Name
Proposer Details
Full Name of Proposer
Father's Name of Proposer
Mother's Name of Proposer
Email
Mobile Number
Date of Birth (DD-MM-YYYY)
Select
Below Secondary
Secondary
Senior Secondary
Graduate
Post Graduate
Educational Qualification
Self Employed
Salaried
Others
Occupation
Annual Income
Select
Single
Married
Divorced
Widowed
Marital Status
Permanent Address
Next
Life Assured & Nominee Details
Same as proposer details.
Full Name of Assured
Father's Name of Assured
Mother's Name of Assured
Date of Birth of Assured
Select
Below Secondary
Secondary
Senior Secondary
Graduate
Post Graduate
Educational Qualification
Self Employed
Salaried
Others
Occupation
Actual Nature of Work
Annual Income
Select
Single
Married
Divorced
Widowed
Marital Status
Full Name of Nominee
Relationship with Nominee
Date of Birth of Nominee
Previous
Next
Policy Details
Name of Plan
Premium Payment Term
Policy Term
Monthly
Quarterly
Half Yearly
Yearly
Mode of Payment
Premium Amount
Previous
Next
Medical & Lifestyle Information
Height In CM
Weight
Drink Alcohol?
Yes
No
Do you smoke or consume Tobacco/Nicotine
Yes
No
Have you ever suffered or are suffering from or been advised to undergo regular medical consultation / investigations or treatment including hospitalization for for any type of illness
Yes
No
Upload Documents
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files are allowed. Maximum file size:
200 KB
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Aadhar (Front)
Aadhar (Back)
PAN
Cancelled Cheque
Photo
Other Document
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