DATA SHEET FOR Policy Holder / Proposer

Application Number
TRACK ID:
PREMIUM AMOUNT: Rs.
Name - Life Assured
Product Name
SUM ASSURED : Rs.
Personal Details
MR / MRS / MISS

Date Of Birth: Gender Marital Status: Nationality

Education: Occupation Annual Income

In Case of Service (mention
Nature of Duties name & address of the
employer)
Do You Have Existing Policy with FGI Yes No If Yes Qoute Policy No.

Father's Name
Complete Name before marriage ( In case of female)
Is your Occupation associated with any specific hazards Yes No
Communication Details

Residence Address:
LandMark

City/Town: Taluka: Dist:

State: Pin: E-mail id:

Telephone : Mobile:

NOMINEE DETAILS

Name: Date Of Birth:

Relationship to Insured Person:

Incase if nominee is a minor - Please provide following appointee details.

APPOINTEE DETAILS

Name Date Of Birth:

Relationship to the Nominee:

Address :

PROOFS DETAILS

Age proof: Address proof: ID proof:

All Proofs should be Clearly SELF ATTESTED BY PROPOSER (CUSTOMER)

Females Only

Are you pregnant.

yes / No If yes - Duration in Weeks Husband Occupation & Annual Income:

SIGNATURE

Leader Name: Place:

Mobile No.
Note :- * Demand Draft on the Name of “ FUTURE GENERALI INDIA LIFE INSURANCE CO LTD” payable at CHENNAI * Incase Insured is
minor, Fill up the 2 data sheet forms - One for child & Another for Proposer - both Data Sheets should be Signed BY Proposer.
Note :- * Demand Draft on the Name of “ FUTURE GENERALI INDIA LIFE INSURANCE CO LTD” payable at CHENNAI * Incase Insured is
minor, Fill up the 2 data sheet forms - One for child & Another for Proposer - both Data Sheets should be Signed BY Proposer.