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▼ Agency Details
▼ Proposer Details
(a) Employment 0 0
(c) H.U.F 0 0
Total 0 300000
▼ Proposer Details
(f).Are you satisfied that the proposed and/or proposer is not ✔ Yes No
connected with any terrorist activities ?
2022-07-13 Page 1 of 2
AGENTS CONFIDENTIAL REPORT/MORAL HAZARD REPORT
Access Id :
3.(a).What is the general state of health of the life ✔ Good Not Good
proposed ?
(b).Does he/she has any physical deformity, impaired
sight or hearing, physical impairment or mental Yes ✔ No
retardation ?
(c).Do you have any knowledge of his/her having Yes ✔ No
suffered from any illness or injury or undergone any
operation or medical investigation ?
4.Did you discuss with the proposer/Life Proposed the ✔ Yes No
status of previous policies and are you satisfied that no
policy has lapsed within the last three years ?
5.Are you aware of any proposal (or revival of any policy)
of the life proposed having been deferred, declines, Yes ✔ No
dropped or accepted at terms other than those
proposed ?
6.Are you aware of anything in the occupation, financial
or social position of the life proposed, his/her personal Yes ✔ No
habits or any other circumstances which might be likely
to add to the risk ?
7.Have you explained fully the terms and conditions of ✔ Yes No
the plan to the proposer ?
▼ Under Non-Medical Proposals
Marks of Identification ?
▼ Declaration
I here by declare that the foregoing statements are true and correct to the best of my knowledge and belief
I am satisfied with the identity of the party on the I am satisfied with the identity of the party on the
basis of my independent enquiries. I here by declare basis of my independent enquiries. I here by declare
that the foregoing statements are true and correct to that the foregoing statements are true and correct to
the best of my knowledge and belief the best of my knowledge and belief
Dated at ........................on the day of ............ 20.. Dated at ........................on the day of ............ 20..
Name and Designation/Standing (No of years) Name and Designation/Standing (No of years)
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