DATA SHEET FOR Policy Holder / Proposer TRACK ID: PREMIUM AMOUNT: Rs.

Application Number Product Name SUM ASSURED : Rs. Personal Details

Name - Life Assured Date Of Birth: Education:

Nature of Duties

MR / MRS / MISS

Gender Occupation

Marital Status:

Nationality Annual Income

In Case of Service (mention name & address of the employer)

Do You Have Existing Policy with FGI Father's Name

Complete Name before marriage ( In case of female)

Yes

No

If Yes Qoute Policy No.

Is your Occupation associated with any specific hazards Yes

No Communication Details

Residence Address: LandMark

City/Town:

Taluka: Pin:

Dist: E-mail id: Mobile:

State: Telephone :

NOMINEE DETAILS

Name: Relationship to Insured Person:

Date Of Birth:

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

Name Relationship to the Nominee: Address :

Date Of Birth:

PROOFS DETAILS Age proof:

Address proof:

ID proof:

All Proofs should be Clearly SELF ATTESTED BY PROPOSER (CUSTOMER) Females Only Are you pregnant. SIGNATURE Leader Name: Place: yes / No If yes - Duration in Weeks Husband Occupation & Annual Income:

Mobile No. Note :- * Demand Draft on the Name of FUTURE GENERALI INDIA LIFE INSURANCE CO LTD payable at DELHI * 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 DELHI * 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.