DETAILS SHEET

1. NAME:

2. DOB (ALL INSURED MEMBERS):

3. ADDRESS:

4. EMAIL ID:
5. MOBILE NO:

6. OCCUPATION:

7. ANNUAL INCOME:

8. EDUCATIONAL QUALIFICATION:

9. PAN CARD NO:

10. HEIGHT(ALL INSURED MEMBERS):

11. WEIGHT(ALL INSURED MEMBERS):

12. NOMINEE NAME & RELATIONSHIP:

13. ANY MEMBER HAVING:

DIABETES:
HEART PROBLEM:
OPERATION:

14. PREVIOUS INSURANCE DETAILS:

15. Chewing Tobacco

16. Any family history of heart attack or cancer