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Insured Name
Mr.
Ms.
Master
Secondary Life Insured’s Name
*
Mr.
Ms.
Master
Proposer Name
Mr.
Ms.
Master
Is the Life Insured same as the Proposer?
Yes
No
Date of Birth of Premium Payer
*
/
/
Proposer Gender
Male
Female
Gender
Male
Female
Date Of Birth Of Insured
*
/
/
Secondary Life Insured’s Gender
Male
Female
DoB Secondary Life Insured
*
/
/
Proposer Gender
Male
Female
Date Of Birth Of Proposer
*
*
/
/
Channel Type
*
Email
Mobile No
Are you a Non-Resident Indian?
*
Yes
No
Will you be able to furnish the Bank Certificate?
Yes
No
Agent’s Branch Location
*
State located in
Proposer’s Current Location
*
Correspondence Address / State
Are you a Tobacco user ?
*
Yes
No
Occupation Of Proposer
Select
Employed
House Wife
Retired/ Pensioner
Self Employed
Self employed /Professional
Student
Occupation Of Insured
Select
Employed
House Wife
Retired/ Pensioner
Self Employed
Self employed /Professional
Student
Income Of Proposer
Category
Select
Employer Employee
Hindu undivided family
Married Women Property
Rural/Urban Not Known
Non Rural
Non Resident Indian
Partnership
Rural Policy
Trust cases
Mode of Premium Payment
*
Select
Cash
Cheque
Demand Draft
Credit Card
Net banking
ECS
SI(Standing instructions)