SHRIRAM LIFE INSURANCE

THIS FORM MUST AND SHOULD FILL BY FLS AND BM

BM/FLS NAME: STFC CODE:
1. FULL NAME * =
2. DATE OF BIRTH* =
3. MARITAL STATUS* =
4. FULL FATHER NAME* =
5. ANNUAL INCOME * =
6. PLAN NAME * =
7. AGE PROOF TYPE * =
8. POLICY TERM * =
9. PREMIUM TERM * =
10. SUM ASSURED * =
11. PREMIUM AMOUNT * =
12. RIDERS (AB AND FIB) * =
13. AGENT CODE and NAME * = ( ) NAME :
14. WEIGHT AND HEIGHT * = AND
15. CELL NO * =
16. EDUCATIONAL QUALIFICATION*=
17. OCCUPTION * =
18. EMAIL ID =
19. NOMINEE DETAILS =
20. ADDRESS WITH PIN CODE * =

FULL NAME RELATIONSHIP WITH LIVE OR DEATH AGE (INCASE)DEATH HEALTH

CUSTOMER BOD STATUS

1)

2)

3)

4)

5)

6)

7)

PLACE AND DATE SING AND SEAL

NOTE: ONLY AFTER RECEIVING PHYSICAL FORM WHICH IS FILLED BY BM AND FLS AND ALONG WITH
SIGNATURES, THEN ONLY PROPOSALS WILL BE ENTERED IN SYSTEM. ORAL CONFIRMATIONS ARE NOT
ALLOWED.