BAJAJ ALLIANZ LIFE INSURANCE COMPANY LTD.
PRODUCT NAME: BAJAJ ALLIANZ LIFE ETOUCH II
Application No: 6156752106
Proposed Insured Name:
MISS Payal Jain
Age :31
Gender :Female
[email protected] / 9015566810
Alternate No : NA
PRODUCT DETAILS
UIN NA Goods and Service Tax - GST 18 %
Sum Assured Rs. 50,00,000 Policy Term 29
Premium Payment Term 29 Amount of Installment Premium Rs.6,867
Portfolio Strategy NA Premium Frequency Yearly
Preferred Renewal Date NA
PROPOSED INSURED DETAILS
IC Code 3WA0000009 Nationality Indian
Date Of Birth 03-09-1993 Purpose Of Policy Investment
Place Of Birth INDIA Sector URBAN
Height 163 cm. Marital Status Married
Weight 59 kgs. Occupation House-Wife
Reason for Weight Change NA Education Graduation And Above
Aadhaar Card Standard Industry OTHERS
Age Proof Nature Of Duties NA,others
Employer's Name NA
NA
Employer's Address NA
Address Proof
Deliver My Policy At NA
NA
ID Proof Annual Income 25,00,000
PAN No. BNRPV2916B
NA
Income Proof
Aadhar Card No./ Aadhar NA
Reference No.
GSTIN No. NA
COVERAGE INFORMATION
Premium Paid by Proposed Insured
Premium Payer's Name Shashank Jain
Relationship to Proposed Insured Self
PAN AVWPJ2830L
DOB 01-06-1991
Gender MALE
Aadhar NA
Address D605 Amba G residency ahinsha khand 2 indirapuram
Pincode NA
NOMINEE DETAILS
Nominee Name Nominee Relationship Reason for not choosing Standard Nominee (Parents,Spouse & Children)
Shashank Jain Spouse
FAMILY DETAILS OF PROPOSED INSURED
Spouse's Date of Birth NA
Husband's Name Lala Ram Verma
Maiden Name NA
Mother's Name NA
Family Member Age Health Status (If alive) Cause of Death Age (When Died)
DECLARATION OF GOOD HEALTH OF PROPOSED INSURED
Chest Pain / Hear Attack / Blood Presure / High Cholosterol / other cardovascular disease or disorder ? No
Asthma / Tuberculosis / any other respiratory disorder ? No
Diabetes / High Blood Sugar / Sugar in Urine / Other Endocrine system disorders such as hypothyroidisam ? No
Genitourinary disorders related to Kidney,Prostate or uninary system ? No
Liver or gall bladder disorders / Jaundice / Hepatitis B or C ? No
Cancer / Tumor / Unusual growth or cyst of any kind ? No
Pancreatitis / Colitis / Recurrent Indigestion / Ulcers / other Gastrointestnal disorders ? No
Any blood disorders like Anemia, Thalassemia, etc ? No
Stroke / Paralysis / Epilepsy / Heart Injury / Other Nervous disorder ? No
Any diseases and disorders of eye, ear, nose, throat No
Any Physical deformity or handicap, joints or muscular disorder, congenital defect or mental / psychiatric disorder No
HIV Infection or postive test of HIV for yourself / spouse / parents ? No
Any Injury /Surgery / Medical condition requiring Hospitalization or any medical condition / disorder not covered No
above ?
In the last 5 years, have you ever had, or been advised to have, or are likely within the next 30 days to undergo No
medical examination or any investigations such as but not limited to blood test, urine test, x-ray, ECG or biopsy,
CT scan or test by any other special instrument ?
Undergone Angioplasty / Bypass Surgery / any other Heart related surgery ? No
Have you ever taken or undergone treatment for narcotics or any addictive drug? No
Have you ever been convicted in the court of law or are there any criminal proceedings pending against you No
before a court?
REFLEX QUESTIONNAIRE FOR DIABETICS
What is the class of diabetes?
Since how many years do you have diabetes?
What was last recorded HbA1c level?
When was it last reported?
What is your height and weight? ,
Are you suffering from high blood pressure? If yes,please provide BP ,
recording in last 6 months
Are you currently taking insulin as treatment?
Have you ever been diagnosed/ treated/ Hospitalised for any
complications arising due to Diabetes Such as Diabetic Nephropathy,
Diabetic Coma, Hypoglycemic shock, Ketoacidosis, Ischemic Heart
Disease, Heart Attack/ Heart Surgery, etc.?
ASSESSMENT QUESTIONNAIRE LIFE ASSURED(LA)
DECLARATION OF GOOD HEALTH OF PROPOSED INSURED (FOR FEMALES ONLY)
Are you pregnant or undergone miscarriage or ectopic pregnancy or abortion in last 3 months? No
Have you suffered / are suffering from or have undergone invetigation or treatment for any gynecological No
complications such as disorders of Cervix, uterus,ovaries,breast, breast lump,cyst etc.
Total Life Insurance coverage on Husband Sum assured 5000000
Annual income of Husband
CHILD DETAILS
Child Name Child DOB % Of SA Guardian Name Relationship
BLACKCAT INFORMATION
FACEBOOK COMMENT NA
TWITTER COMMENT NA
LINKEDIN COMMENT NA
INSTAGRAM COMMENT NA
DECISION COMMENT NA
DECISION STATUS NA
