Scribd
Upload
13K views

Lic Data Sheet

This document contains a life insurance data sheet requesting personal and family details such as name, address, date of birth, occupation, income, previous insurance policies, family medical history, physical details, and signature of the applicant. The information will be used to process an application for a life insurance policy.

Uploaded by

Ashis Kumar Mishra
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
13K views

Lic Data Sheet

This document contains a life insurance data sheet requesting personal and family details such as name, address, date of birth, occupation, income, previous insurance policies, family medical history, physical details, and signature of the applicant. The information will be used to process an application for a life insurance policy.

Uploaded by

Ashis Kumar Mishra
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

LIC DATA SHEET

Please fill in Capital letters only.


Track Id. No. :- __________________

Mob. No. :- ________________________________________

Name in full :- __________________________________________________________________________


Fathers full name :- _____________________________________________________________________
Present address :- ________________________________________________________________________
______________________________________________________________________________________
Occupation :- ___________________
Name of Employer :- ____________

Nature of work :- _____________________________________


Length of service :- ____ Yrs.

PAN No. :- ___________________

Date of birth :- _________________

Place of birth :- _______________ Age. :- ____________________

Education :- _____________

Income :- _____________

Tax Payer :- Yes / No

Name of Nominee :- _______________ Relationship :- ____________

FAMILY HISTORY
Relationship

Age.

Age of death

Age :- _______________

DETAILS OF PREVIOUS INSURANCE


Cause of
death

Policy No

S.A

Mode

T/T

D.O.C

Father
Mother
Brothers
Sisters
Husb/Wife
Children

Height :-_____ Weight :- _____ Abdomen :- _____ Chest :- ____ Identification :-________________________

In case of Female proponent :Last delivery date :- ________________ Abortion / miscarriage / pregnancy desea
Maiden Name :- ___________________________________________________________________________
Husbands full Name :- _____________________________________________________________________
His occupation :- ______________________

Yearly Income :- _____________

Policy No. 1) __________ 2) ____________ 3) ___________

Date :- ___________

4) ___________

Tax Payer :- Yes / No


5) ____________

Specimen Signature :- ____________________

You might also like