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Details Form

This document contains details for an insurance policy proposal, including the customer's personal information like name, address, income, family medical history, nominee details, and any notes. It lists the plan term, premium amount, and advisor code. The customer and witness signatures are at the bottom to finalize the proposal.

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muukunthna
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
10 views2 pages

Details Form

This document contains details for an insurance policy proposal, including the customer's personal information like name, address, income, family medical history, nominee details, and any notes. It lists the plan term, premium amount, and advisor code. The customer and witness signatures are at the bottom to finalize the proposal.

Uploaded by

muukunthna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Plan:-………..……….. Proposal No:-……………………………….

Term:-………..………. Policy No:-……………………………………..

Premium:-…..………. Advisor Code:-………………………………

Mode:-……………….. Date:-…………………………………………..

Customer Details

 Full Name:-……………………………………………………………………………………………………………………………
 Address:-………………………………………………………………………………………………………………………………..
 Telephone No:-………………………………………………………………………………………………………………………
 Email Id:-…………………………………………………………………………………………………………………………………
 NIC/Passport No:-……………………………………………………………………………………………………………………
 Date of Birth:-……………………………………Age:-……………………………………………………….Sex:-……………
 Health Status:-………………………………………………………………………………………………………………………..
 Height:-…………………………………………………………….Weight:-……………………………………………………….
 Father Full Name:-…………………………………………………………………………………………………………………..
 Mother Full Name:-…………………………………………………………………………………………………………………
 Occupation:-………………………………………………..Nature of Occupation:-…………………………………….
 Name of Employer-…………………………………………………………………………………………………………………
 Employer Telephone No:-……………………………………………………………………………………………………….
 Address:-………………………………………………………………………………………………………………………………..
 Period of Employment:-……………………………………………………………………………………………………….
 Business Registration Number:-………………………………………………………………………………………………
 Monthly Income:-……………………………………………………….Annual Income:-………………………………..
 Account holder Name:-……………………………………………………………………………………………………………
 Account Number:-…………………………………………………………………………………………………………………..
 Bank Name:-…………………………………………………………………..Branch:-………………………………………..

Family History
No Relation Age Living Death
State of Surgery Age of Cause of
Health Details Death Death
1 Father
2 Mother
3 Husband/Wife
4 Son/Daughter
5 Sister/Brother
6
7
8
9
10
11
12

Signature:-……………………………….. Witness Signature:-…………………………………………

Date:-…………………………………………
Nominee Details

 Nominee Full Name:-………………………………………………………………………………………………………………


 Address:-………………………………………………………………………………………………………………………………..
 Telephone No:-………………………………………………………………………………………………………………………
 Email Id:-…………………………………………………………………………………………………………………………………
 NIC/Passport No:-……………………………………………………………………………………………………………………
 Date of Birth:-……………………………………Age:-……………………………………………………….Sex:-……………
 Health Status:-………………………………………………………………………………………………………………………..
 Height:-…………………………………………………………….Weight:-……………………………………………………….
 Father Full Name:-…………………………………………………………………………………………………………………..
 Mother Full Name:-…………………………………………………………………………………………………………………
 Occupation:-………………………………………………..Nature of Occupation:-…………………………………….
 Name of Employer-…………………………………………………………………………………………………………………
 Employer Telephone No:-……………………………………………………………………………………………………….
 Address:-………………………………………………………………………………………………………………………………..
 Period of Employment:-……………………………………………………………………………………………………….
 Business Registration Number:-………………………………………………………………………………………………
 Monthly Income:-……………………………………………………….Annual Income:-………………………………..

 Child Name:-…………………………………………………………………………………………………………………………
 Child Date of Birth:-……………………………………..Age:-……………………………Sex:-………………………….
 Birth Certificate No:-…………………………………………………………………………………………………………….
 Health Status:-……………………………………………………………………………………………………………………..

Notes:-
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