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Hornmerchant
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Life Inurance Proposal Data Form
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Full Name
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Maiden Name (for female Proposers)
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Father's / Husband's Name
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Date of Birth
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Proof of AgeAttach Scanned image / copy of PAN Card / Passport / Driving License
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Gender
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Nationality
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Do you smoke?
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Height
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Weight
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Education
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PAN
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Proof of PANAttach Scanned image / Copy of PAN Card
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Aadhar No.
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Gross Annual Income
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Income Proof
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Marital Status
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Employer (Company) Name & Address
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Nature of Business of the Orgnization
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Designation
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Occupation & Nature of duty
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Current Residence Address (for Medical Tests etc)
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Current Residence Address Proof
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Permanent Address (If Different from above)
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Permanent Address ProofAttach Address Proof (Mandatory)
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Coomunication AddressCurrent Residence Address / Permanent Address
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Mobile No.
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E-mail ID
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Nominee-1 Full Name
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Date of Birth (Nominee-1)
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Relationship with nominee-1
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Nominee-2 Full Name (Optional)
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Date of Birth (Nominee-2)
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Reltaionship with nominee-2
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Appointee Name (In case nominee is minor)
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Appointee Date of Birth
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Relationship with nominees
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Notes
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Heatlh Questionnaire
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Do you smoke/consume Tobbacco?
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Do you consume Alcohol?
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If answer to any of the above is "Yes", please provide the details about quanitity per week
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Were you tested positive for Covid-19?
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Do you have any pre-exsting health Contions (Ex: Diabetes, Hypertension, etc)
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Have You undergone any surgery in your life time?
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Do you have any disability, discorder, any health related issues?
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Have taken leave or remained absent to work continuously for a perid of 15 days or more on medical grounds?
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Have any of your immediate blood relatives died before the age of 55?
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If answer to any of the above is "Yes", please provide the details
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Existing Ins. Policy-1 No
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Existing Ins. Policy-1 issuing company
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Existing Ins. Policy-1 Sum Assured
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Existing Ins. Policy-1 Issued asStandard / Postponed / Condition
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Existing Ins. Policy-2 No
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Existing Ins. Policy-2 issuing company
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Existing Ins. Policy-2 Sum Assured
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Existing Ins. Policy-2 Issued asStandard / Postponed / Condition
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Existing Ins. Policy-3 No
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Existing Ins. Policy-3 issuing company
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Existing Ins. Policy-3 Sum Assured
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Existing Ins. Policy-3 Issued asStandard / Postponed / Condition
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Existing Ins. Policy-4 No
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Existing Ins. Policy-4 issuing company
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Existing Ins. Policy-4 Sum Assured
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Existing Ins. Policy-4 Issued asStandard / Postponed / Condition
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Own a Car?
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Own a House?
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Have any Loan? If Yes, oustanding Balance
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Notes
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