Name:
Date of Birth:
Age:		Years (only number format)
NIC #:
Marital Status:	Select Married Unmarried Divorced Separated
Address:
City:
Contact #:
Email:
Profession:
Monthly Income:
Company:
Designation:
Do you have Provident Fund in your Organization?		YESNO
Is your organization allowing employees to buy Life Insurance through Provident fund?		YESNO Don't Know
How much amount you can save anually?
Yearly Saving Rs.
Would you like to have our Insurance Plus Investment Plan?		YES NO
Are you already Insured by any Life Insurance Company?		YES NO
Do you want to plan your Retirement Benefits with Us?		YESNO Amount Needed:
Do you want to plan your Children Education & Marriage Expense with Us?		YESNO Amount Needed:
Do you want to Cover yourself and your spouse both in one Policy?		YESNO Amount Needed:
		Total Amount Required:
Are you in good heath?		YESNO
How much Premium you can afford Annually Rs.
When you want to take the policy Now Or Specify:
Available at Date/Time
00018741