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Life Insurance Form
Full Name
*
Email
*
Date of Birth
*
Any Visible Mark
*
Maiden Name
*
Spouse Name
*
Mother's Name
*
Address
*
Address (As per Aadhar card)
*
Phone
*
Educational Qualification
*
Marital Status
*
Married
Single
Occupation
*
Designation
*
Gross Annual Income
*
Company Name
*
Company Address
*
Industry
*
Height (in feet)
*
Weight (in kgs)
*
Nominee Name
*
Nominee Date of Birth
*
Relationship with Nominee
*
Family Doctor Name
*
Family Doctor's Address
*
Previous Insurance Details
*
Year of Policy Taken
*
Previous Medical history- have you ever suffered from ::
*
Diabetes
Blood Pressure
Heart Disease
Other
Are you under medication if 'Yes' please Specify
*
Any Operation OR Hospitalization in last 5 years
*
Yes
No
Tobacco
*
Yes
No
Alcohol
*
Yes
No
Aadhar Card (Front)
*
Upload File
Aadhar Card (Back)
*
Upload File
PAN Card
*
Upload File
Cancelled Cheque/Passbook
*
Upload File
Nominee PAN
*
Upload File
Photo
*
Upload File
Signature
*
Upload File
Submit
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