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Life Insurance Form
Full Name
Email
Date of Birth
Any Visible Mark
Maiden Name
Spouse Name
Mother's Name
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
Sum assured
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
Upload supported file (Max 15MB)
Aadhar Card (Back)
Upload File
Upload supported file (Max 15MB)
PAN Card
Upload File
Upload supported file (Max 15MB)
Cancelled Cheque/Passbook
Upload File
Upload supported file (Max 15MB)
Nominee PAN
Upload File
Upload supported file (Max 15MB)
Photo
Upload File
Upload supported file (Max 15MB)
Signature
Upload File
Upload supported file (Max 15MB)
Submit
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