LIC Data Sheet Application

LIC DATA SHEET

Please fill in Capital letters only. All fields are optional.

Policy Details

Plan Number

Sum Assured

PPT (Policy Term)

Mode of Premium

Premium Amount

Personal Information

Track Id. No.

This will auto-generate if left empty. Must be unique.

Mob. No.

Email ID

Name in full

Father's full name

Present address

Occupation

Nature of work

Name of Employer

Length of service (Yrs)

Date of birth

Place of birth

Age

Education

Income

Tax Payer

Yes No

Name of Nominee

Relationship

Age

FAMILY HISTORY

Relationship	Age	Age of death	Cause of death
Father
Mother
Brothers
Sisters
Husb/Wife
Children

DETAILS OF PREVIOUS INSURANCE

Policy No	S.A	Mode	T/T	D.O.C

Physical Details

Height

Weight

Abdomen

Chest

Identification

In case of Female proponent

Last delivery date

Abortion / miscarriage / pregnancy details

Maiden Name

Husband's full Name

His occupation

Yearly Income

Tax Payer

Yes No

Policy No.

Date

Specimen Signature

Track Records

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