Life Insured’s Details

Name of the Life Insured/Annuitant	Mr. Ms. Mrs. Mast.
Gender *	Male Female	Region *	Rest of India Jammu and Kashmir
Date of Birth (dd/mm/yyyy)*		Present Age
Is the Life Insured same as the Proposer? *	Yes No
Name of Proposer	Mr. Ms. Mrs. Mast.
Date of Birth of Proposer		Proposer Age
Do you want to backdate the policy?	Yes No
If yes, kindly specify the backdation date
Are you a Tobacco user ?	Yes No	Tax Bracket *	30.9% 20.6% 10.3% 0%
Are you a Non-Resident Indian? *	Yes No
For GST exemption, Bank Certificate is required stating amount paid in Convertible Foreign Exchange
Will you be able to furnish the Bank Certificate?		Yes No
Agent’s Branch Location *	Select Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chattisgarh Daman Diu Dadra Nagar Haveli Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Ladakh Lakshadweep Islands Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal	Proposer’s Current Location *	Select Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chattisgarh Daman Diu Dadra Nagar Haveli Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Ladakh Lakshadweep Islands Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal Foreign Country
Email		Mobile No
Occupation of Proposer	Select Employed House Wife Dummy Code for OTC Retired/Pensioner Self Employed Self Employed/Professional Student	Occupation of Insured	Select Employed House Wife Dummy Code for OTC Retired/Pensioner Self Employed Self Employed/Professional Student
Income of Proposer		Category	Select Electronic Cl. System 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)	Channel Type*	Select Individual Agents Corporate Agent Broker Direct Marketing

Future Benefits

Premium Payment Term

10

Income Benefit Payout

Select Yearly Monthly

Frequency of Premium Payment

Yearly Half Yearly Quarterly Monthly

Premium Budget *			Payout Age
	Policy 1*
	Policy 2 *
	Policy 3 *

Fields marked * are mandatory