Proposer’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

Plan your retirement

Annuty Required from age *

Option I (Desired Annuity wise)		Option II (Premium Budget wise)
Desired Annuity *		Growth Scenario	4% 8%
Premium Budget *

Frequency of Premium Payment *	Yearly Half Yearly Quarterly Monthly	Premium Paying Term select
Frequency of Annuty Payment *	Yearly Half Yearly Quarterly Monthly
Annuity Option *	Lifetime Income Lifetime Income with Cash Back Lifetime Income with term Guarantee Last Survivor Lifetime Income with 100 percent Annuity to Surviving Spouse Last Survivor Lifetime Income with 50 percent annuity to Surviving Spouse Last Survivor Lifetime Income with 100 percent to the Surviving Spouse and Cash back on death of Surviving Spouse
Guarantee Term *	5 10 15 20
Client Category *	New Customers Existing Pension Plan Policyholders of KLI
Policy Number *
Spouse Date of Birth(dd/mm/yyyy)*		Spouse Present Age
Spouse Name *	Ms. Mr. Mrs. Mast.
Gender	Male Female

Fields marked * are mandatory