cfur rsrrdt fu ron FEMALE pRopoNENT

13q'.(A) Bfl-srTq'tT$fill f? 3ITflI g-q 'ftrfel RT slrqmt E^sft rrqqrd qi rrctsltr sr tM'qfun Ed'
frr$ftq-{ E-qr qi? qR 6r ai ft-+rur SGqr fr ftts frtu-tr
Are you pregnant now? Date of last delivery Have you had any abortion or miscarriage Date of last menstruation
or Ceasarean section? lf so, give details

13.(B) qft 4.r qu crcl 3{frrqmnE / 3-r-ff Ertr6. 3fl-q

Husband's full name His occupation His annual lncome
I
I
I

13n (C) Tft + dt+ + gwRrd G-d{ur frtrq /Detaits of Husband,s tnsuiance
firffi-sr frcr aqfr-qi q+ HFa q-di + ffi qrffiNrfrfrqf ftcr efi drR-fi q{ ftfrrS*
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* t + ?Trqr/tra,.znr qrc t)
Policy number lnsurance companies from where the previous policy/ Sum Assured Table & Term Present
policies have been purchased with address (if previous
status of
policies are from LIC of lndia, give name of Branch /D.O.)

14. Err sTM+ nmtr{ +s{r fi

ftqc ruT Tr# 6} qofa: frur r*-g
Have you understood fully the terms & conditions of the plan you propose to take?
t: Ei/Tfr'
Yes/No
15 Hr 6crt qM' I silq-*t TRrG-il +q-{r * ftqq e rr# xFrdr t" Eiul-ff
whether the terms & conditions of the proposed plan have been explained to you by YeVNo
the Agent?

]Q$flf ig ffifrr qrf,i5,lt trpr*"" provirle the ffiroving hformarirn b hetp us to serve y", b"-*.
3Tl[fif fif, ftr 6.f lifRur / BankAccount details :

6,) ar* 6.r qfiR - cqr& a) Type otAccount-savingGnrent $ env; 6 * qrc altt sdr e) l'ame andAddress cf your
bank :

6.) sTrq+ qr* eT xgifi : b) yourAccount No.___._..=-

T) + 3rs-drmr g+emr$sm : c) 9 Digit MICR
a.) 3nS qm, q{r fi *e : d) IFSC Code :

Iq ffi 3q et-{rt{r * qfi Brqr - qft E q[i *- qrer +ia.+ atrlnttach a photocopy or canceiled cheque with the form.

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Auttl*riiy 0f lndie (UIDAI).
sulhcriee Lfc ot lndh k &irs Iryc dstaik of Aadrsa &ffir tl}e unlque ldsniifi0atiorl
'vly

nlsi0resoins*b****;-
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and tiat I have nol withhelo anv inlomralion ard l tre*ety agree and 'ded*-dt{d--
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Hffi-XnffiLffiffiffitH;fr,1,,*r"[,ffiJ*
u*uranoe betrrve'*n me a** the Life tns$renoe corporation or tid*a and
;d;;il ;J
uri tJ"ori." stufi be the b*sts of the conkact of
nat ii *ny *n*e *ven*ent be con&ind t the e6id c*nt afi sh*lr be dealt with as
per provisions of Sscti}n 45 Ot the ln&rranoe La$,s
{Arfidrne$l} ACt, 2015. 'erei*
sny k*sr@ or i*{ornation abour me concgftirq mv rree{rr
y. *l|np,"yt#il, #'&*nd*
o'r any otlrr pefon or prians, hqvint of-u*"r"*y"
inlerE$t or any kin$ *xraxoev& in tir"- polici cantncut iasued
i ;i
;ei;, ***utor*, adnninistrataes and a,ssigr!s$
to n*- t*reuy agres gla* sucf., *urhsrity, having su*,..r
knowtedg+ o infonnstian. shall at any *rnc b et rikrti tD divuge any ui*tr Lnc,J$
ou irrrormetlon to r ssrp$Etic,n.
-4-