CUSTOMER INFORMATION FORM

(Please fill this form if you are interested in availing Bank's other products)

Branch SOL ID : Date :

Customer Name : _____________________________________________________ Existing Customer : Yes / No

If Yes, please provide account number :
Contact Number :

Please select the appropriate block and fill in the details as required

Products :

Information Customer Response

Assets Home Loan Which type of loan you are looking for? Home Loan Balance Transfer of existing loan
Top UP Loan against property
Others __________________________________

How much loan are you looking for? < 30 Lacs 30 to 75 Lacs > 75 Lacs

When are you looking at taking the disbursement? < 1 Month 1 to 3 Months > 3 Months

Personal Loan What is the purpose of the loan? Renovation Travel Wedding

Others ___________________________

What is the loan amount you are looking for? < 3 lacs 3 to 5 lacs 5 to 10 lacs

> 10 lacs
When are you looking at taking the disbursement? Immediate Within 1 Month > 3 Months

Auto Loan Which vehicle do you plan to buy? Hatch Back Sedan SUV

MUV

What is your Loan requirement? < 5 lacs 5 to 10 lacs > 10 lacs

When are you looking at taking the disbursement? < 3 Months 3 to < 6 Months 6 to< 9 months
9 to 12 Months

RIB Assets Farmer What is the purpose of the loan? KCC (Crop Loan) KCC (Crop Loan) Dairy - Milch
Finance - Fresh - Takeover Animal Purchase
Land Development - Irrigation

(ATL + KCC) What is the loan amount you are looking for? < 3 lacs 3 to 5 lacs 5 to 10 lacs

> 10 lacs
When are you looking at taking the disbursement? < 1 Month 1 to 3 Months > 3 Months

Farm Which model of tractor you wish to purchase? ____________________________________________________

Equipment
(Tractor & Do you want to purchase Tiller? Yes NO
Tillers)

Rural Based What was your turnover last year ? 40 lacs to 1 crore 1 to 5 Crores > 5 Crores
Credit
(OD, CC limits) How much OD/CC limit are you looking for? < 25 lacs 25 lacs to 1 Crore 1 to 5 Crores
> 5 Crores
When are you looking at taking the disbursement? < 1 Month 1 to 3 Months > 3 Months

Commodity Which godown do you normally store your SWC CWC Private Godown
Based Finance produce in?
(Warehouse What was your turnover last year ? > 1 crore 1 to 5 Crores > 5 Crores
Funding)
When are you looking at taking the disbursement? < 1 Month 1 to 3 Months > 3 Months

Gold Loan What is the loan amount you are looking for? < 3 lacs 3 to 5 lacs 5 to 10 lacs
(Loan against
Gold Ornaments) > 10 lacs

When are you looking at taking the disbursement? < 1 Month 1 to 3 Months > 3 Months

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 Information Customer Response

Insurance Life Insurance Do you have an existing life cover for you and Yes NO
your family?
Have you planned for your financial goals like Yes NO
building wealth, securing child's education or
planning your retirement?

General Do you have any health Insurance cover for you Yes NO
Insurance and your family?
Is there any medical exigency cover provided by Yes NO
your employer? If yes,
Up to what sum insured: Rs. _____________________________

Motor Insurance Do you have a motor Insurance ? Yes NO

With which insurance company is your vehicle Co Name : ___________________________________________

insured and can you share when the policy is
Date : __________________
due for renewal?

Card Credit Card Do you have a credit card? Yes NO

Which Bank Credit Card do you hold ________________________________________

Forex Forex Do you trave abrad for vacation or business? Yes NO

Do you have family members staying/studying Yes NO

abroad?

PPF PPF Account Which investment option you use for saving LI NSC
Income Tax?
PPF Others___________________________

Deposits Savings Are you planning to shift your savings account? Yes NO
Account
Which Bank Savings Account do you hold? ________________________________________

Will you be interested in opening accounts of Yes NO

your family member?

Term Have you invested in fixed deposit/recurring Yes NO

Deposits deposit with any other bank?

Which product you are interested in? Fixed Deposit Recurring Deposit Tax saver FD

What amount you would like to invest? Rs. ____________________

Current Who is your existing Banker ? ___________________________________________

Account
What is your annual turn over ? < 50 Lacs 50 Lacs to < 5 Crore
5 Cr. to 10 Crore > 10 Crore

Average number of transactions in a month? _____________________________________________

Customer Declaration
I would like to get the additional information on the products. I / We would like to get information on the products selected above. ICICI Bank or its group
companies may provide the information by phone, sms, email or such other means as they may deem fit. I / We understand that in order to avail any of the
above products I / We shall be required to complete the required documentation.

Signature : ________________________________

To be filled by Bank Official (All details including PIN Code must be filled)
Original Product Souced : Savings A/c Current A/c Home Loan Personal Loan Auto Loan Credit Card (Specify product)
Others ____________________

PIN Code :
Employee Name :____________________________________________________________________________________

Employee ID :
Signature : ______________________________
ICICI/RSPPG/BR_Walk_Ins_Ver1.0