Customer Name

Customer Email

Phone Number

Aadhhar Number

PAN Number

Date of Birth

Father Name

Mother Name

Suspose Name

Family Information (Live)

Family Information (Death)

Height

weight

Health Status
—Please choose an option—GoodDecised

Qualification

Employement Type

yearly Income

BANK NAME

Account Holder Name

Account Number

IFSC Code

Account Type
—Please choose an option—SavingsCurrentJoint

Submit for Auto Diduction (Nack)
—Please choose an option—YesNo

Nominee Name

Nomini Aadhar

Date of Birth

Nominee Email

Nomini Phone

Relation

Policy Value

Term
—Please choose an option—151617181920212223

Payment Mode
—Please choose an option—MonthlyQuaterlyHalf Yearlyyearly

Policy ID

Agent ID

Agent Email

Agent Name